Academic literature on the topic 'Health and hygiene, Rwanda'

Purpose Post-cesarean wound infection (PCWI) is a common post-operative complication that can negatively affect patients and health systems. Poor hand hygiene practice of health care professionals is a common cause of PCWI. This case study aims to describe how strategic problem solving was used to introduce an alcohol-based hand rub in a district hospital in Rwanda to improve hand hygiene compliance among health care workers and reduce PCWI. Design/methodology/approach Pre- and post-intervention study design was used to address the poor hand hygiene compliance in the maternity unit. The hospital availed an alcohol-based hand rub and the team provided training on the importance of hand hygiene. A chart audit was conducted to assess the PCWI, and an observational study was used to assess hand hygiene compliance. Findings The intervention successfully increased hand hygiene compliance of health care workers from 38.2 to 89.7 per cent, p < 0.001, and was associated with reduced hospital-acquired infection rates from 6.2 to 2.5 per cent, p = 0.083. Practical implications This case study describes the implementation process of a quality improvement project using the eight steps of strategic problem solving to introduce an alcohol-based hand rub in a district hospital in Rwanda. The intervention improved hand hygiene compliance among health care workers and reduced PCWI using available resources and effective leadership skills. Originality/value The results will inform hospitals with similar settings of steps to create an environment that enables hand hygiene practice, and in turn reduces PCWI, using available resources and strategic problem solving.

Purpose The purpose of this study is to improve the hand hygiene compliance in a hospital in Rwanda. Hand hygiene is a fundamental routine practice that can greatly reduce risk of hospital-acquired infections; however, hand hygiene compliance in the hospital was low. Design/methodology/approach A multiple-strategy intervention was implemented with a focus on ensuring stable water supply was available through installing mobile hand hygiene facilities. Findings The intervention significantly increased the overall hand hygiene compliance rate by 35 per cent. The compliance for all of the five hand hygiene moments and all professions also significantly increased. Practical implications By implementing an intervention that involved multiple strategies to address the root causes of the problem, this quality improvement project successfully created an enabling environment to increase hand hygiene compliance. The hospital should encourage using the strategic problem-solving method to conduct more quality improvement projects in other departments. Originality/value Findings from this study may be useful for hospitals in similar settings seeking to improve hand hygiene compliance.

Problem A lack of proper water, sanitation, and hygiene (WASH) infrastructure and poor hygiene practices reduce the preparedness and response of health care facilities (HCFs) in low-income countries to infection and disease outbreaks. According to a World Bank Service Provision Assessment conducted in 2007, only 28% of HCFs in Rwanda had water access throughout the year supplied by tap and 58% of HCFs provided functioning latrines. 1 This evaluation of services and infrastructure in HCFs in Rwanda indicates that targets for WASH in-country need to be enhanced. Objectives To present a case study of the causes and management of sepsis during delivery that led to the death of a 27-year-old woman, and propose a WASH protocol to be implemented in HCFs in Rwanda. Methods The state of WASH services used by staff, caregivers, and patients in HCFs was assessed in 2009 in national evaluations conducted by the Ministry of Infrastructure of Rwanda. Site selection was purposive, based on the presence of both water and power supply. Direct observation was used to assess water treatment, presence and condition of sanitation facilities and sterile equipment in the delivery room, provision of soap and water, gloves, alcohol-based hand rub, and WASH-related record keeping. Results All healthcare facilities met Ministry policies for water access, but WHO guidelines for environmental standards, including for water quality, were not fully satisfied. Conclusions The promotion and provision of low-cost technologies that enable improved WASH practices could help to reduce high rates of morbidity and mortality due to infection in low-income countries.

Unsafe drinking water contributes to diarrheal disease and is a major cause of morbidity and mortality in low-income contexts, especially among children under five years of age. Household-level water treatment interventions have previously been deployed in Rwanda to address microbial contamination of drinking water. In this paper, we describe an effort to integrate best practices regarding distribution and promotion of a household water filter with an on-going health behavior messaging program. We describe the implementation of this program and highlight key roles including the evaluators who secured overall funding and conducted a water quality and health impact trial, the promoters who were experts in the technology and behavioral messaging, and the implementers who were responsible for product distribution and education. In January 2019, 1023 LifeStraw Family 2.0 household water filters were distributed in 30 villages in the Rwamagana District of Rwanda. Approximately a year after distribution, 99.5% of filters were present in the household, and water was observed in 95.1% of filters. Compared to another recent water filter program in Rwanda, a lighter-touch engagement with households and supervision of data collection was observed, while also costing approximately twice per household compared to the predecessor program.

Rwanda met the Millennium Development Goal targets for access to drinking water and sanitation. However, the WASH practices of high-risk communities are undocumented. Lack of information may hide disparities that correlate with disease. The purpose of this study was to assess WASH and childhood diarrhoea in Bugesera District. A survey was administered to caregivers. Water and stool samples were collected to assess physical and biological characteristics. Focus groups provided information on community context. Analysis included descriptive statistics, Chi-square, logistic regression, and thematic analysis. Piped water and unimproved sanitation were used by 45.28 per cent and 88.38 per cent of respondents. Most respondents (51.47 per cent) travelled 30–60 minutes per trip for water and 70 per cent lacked access to hand-washing near the latrine. Diarrhoea was less prevalent in children who used a toilet facility (p = 0.009). Disposal of faeces anywhere other than the toilet increased the odds of having diarrhoea (OR = 3.1, 95 per cent CI = 1.2–8.2). Use of a narrow mouth container for storage was associated with decreased intestinal parasites (p = 0.011). The presence of a hand-washing station within 10 metres of the toilet was associated with lower odds of intestinal parasites (OR = 0.54, 95 per cent CI: 0.29–0.99). Water and sanitation access, water handling and storage, and unsanitary household environment underlie high diarrhoeal disease prevalence.

The purpose of this study was to better understand the gender violence risks that exist in communities where poor water, sanitation, and hygiene (WaSH) access is a known problem. Focus groups and key informant interviews were used to capture the lived experiences of community and health care practitioners from Rwanda, Tanzania, Uganda, and Kenya. This article provides lived narratives of the various cultural and environmental conditions leading to assaults directly attributable to inadequate WaSH. The results shed light on the complex intersections between water access and violence and have significant implications for achieving gender equity and universal access to WaSH.

Abstract Safe water, sanitation, and hygiene (WASH) is critical for the prevention of postpartum infections. The aim of this study was to characterize the WASH conditions women are exposed to following cesarean section in rural Rwanda. We assessed the variability of WASH conditions in the postpartum ward of a district hospital over two months, the WASH conditions at the women's homes, and the association between WASH conditions and suspected surgical site infection (SSI). Piped water flowed more consistently during the rainy month, which increased availability of water for drinking and handwashing (p &lt; 0.05 for all). Latex gloves and hand-sanitizer were more likely to be available on weekends versus weekdays (p &lt; 0.05 for both). Evaluation for suspected SSI after cesarean section was completed for 173 women. Women exposed to a day or more without running water in the hospital were 2.6 times more likely to develop a suspected SSI (p = 0.027). 92% of women returned home to unsafe WASH environments, with notable shortfalls in handwashing supplies and sanitation. The variability in hospital WASH conditions and the poor home WASH conditions may be contributing to SSIs after cesarean section. These relationships must be further explored to develop appropriate interventions to improve mothers’ outcomes.

Water-, sanitation-, and hygiene-related diseases are killing many people each year in developing countries, including Rwanda, and children under the age of five are the most vulnerable. This research assessed human waste disposal practices, knowledge on diseases caused by contact with human faeces, and knowledge on causes and prevention of selected WASH-related diseases. One thousand one hundred and seventy-three students were interviewed out of 2900 students. The results showed, regarding students’ waste disposal practices, that 96.3% use latrines, 20.5% practice open defecation in bushes, and 3.2% defecate in water bodies. Regarding knowledge on diseases caused by contact with human faeces, 56.9% responded that they were aware of cholera, 26.5% of diarrhoea, 2.2% of dysentery, 0.3% of malaria, 0.1% of shigellosis, and 3.8% of typhoid. The majority of the respondents, between 50–99%, could not identify the main causes of the WASH-related diseases. This paper also showed that students lack health knowledge in regard to WASH-related diseases’ causes and prevention. Therefore, the provision of water and sanitation infrastructures should go with the provision of health education on how to avoid these diseases and possible ways to improve the well-being of the students both at home and in their various schools.

According to literature, particularly from data obtained from the World Health Organisation, physical inactivity or sedentarism is one of the leading causes of the major non-communicable diseases, which contributes substantially to the global burden of diseases, death and disability. The burden of mortality, morbidity and disability attributable to non-communicable diseases is currently greatest and is continuing to grow in the developing countries. Most declines in physical activity are during the transition from high school to college or university. The aim of the study was to ascertain perceptions of physical activity, specifically
perceived benefits of, perceived barriers and perceived helpful motivational factors to physical activity among tertiary institution students in Rwanda, and to find out whether demographic and background characteristics have an influence on these perceptions.

Health systems worldwide fail to produce optimal health outcomes, and successive reforms have sought to make them more efficient, more equitable and more responsive. The overarching objective of this thesis is to explore how to motivate healthcare providers in improving performance in service delivery in low income countries. The thesis explores whether financial incentives for healthcare providers raise productivity and how they may affect equity in utilization of healthcare services and responsiveness to patients’ needs. The thesis argues that, as performance-based financing (PBF) focuses on supply side barriers, it may lead to efficiency gains rather than equity improvements. It uses data from a randomized controlled impact evaluation in Rwanda to generate robust evidence on performance-based financing and address a gap in the knowledge on its unintended consequences. Statistical methods are used to analyze four aspects: the impact on health workforce productivity; the impact on health workforce responsiveness; the impact on equity in utilization of basic health services; and, the impact on spatial disparities in the utilization of health services. Findings indicate that performancebased financing has a positive impact on efficiency: it raises health workforce productivity through higher workload and lower absenteeism; and, it encourages healthcare providers to be more responsive which positively impacts the quality of care perceived by patients. Findings also indicate that the impact on equity is uncertain as PBF can deter equity in access for the poorest in the absence of a compensating mechanism; however, PBF is a powerful reform catalyzer and can reduce inequalities between regions and households when combined with appropriate reforms that control for its potential perverse effects. This thesis advocates that strategies aiming to raise healthcare providers’ motivation should be used to raise performance in service delivery in low-income countries with particular attention to their effect on end users.

Bisher wurden die Einzugsgebiete der Gesundheitszentren mit den administrativen Grenzen des Sektors, in dem das Gesundheitszentrum liegt, gleichgesetzt. Das Hauptanliegen dieser Arbeit ist es, die tatsächlichen Einzugsgebiete zu erfassen und bisher verwendete methodische Ansätze auf ihre Eignung zu testen, Einzugsgebiete für Gesundheitszentren möglichst realistisch zu modellieren. Darüber hinaus sollen Gründe für räumliche Unterschiede in der Inanspruchnahme von Gesundheitszentren ermittelt werden. Fragenbögen, die mit Patienten in den Gesundheitszentren ausgefüllt wurden, sowie aus Registrierungsbüchern erfasste Daten geben Aufschluss über die räumlichen Unterschiede bei der Inanspruchnahme und dienen als Referenzdaten für die weiteren Analysen. Die Studie zeigt, dass keine der getesteten Methoden dazu geeignet ist, die Einzugsgebiete zufriedenstellend zu modellieren. Ein selbst entwickelter Ansatz, der verschiedene Methoden kombiniert, liefert bezüglich der Bevölkerung nur zweitbeste Ergebnisse nach Thiessen Polygonen, während für keine der Methoden die Grenzen mit den Grenzen übereinstimmen, die für die tatsächliche Nutzung ermittelt wurden.
Until now catchment areas of health centers are considered as the administrative boundaries of the sector where the health center is situated. The main objective of this study is to determine the actual catchment areas of health centers in Huye District (Southern Province, Rwanda) and to test approaches used in other studies in a geographical information system for an improved estimation of catchment areas. Furthermore reasons for disparities in health center utilization are to be revealed. Questionnaires filled with patients at health centers as well as data retrieved from registration books aim to give information about spatial disparities in health center utilization and serve as evaluation basis for further analysis. The study shows that none of the tested methods is able to predict catchment areas or the population to be served in a satisfying accuracy. An own approach that combines different methods gives only second best results after Thiessen polygons regarding the served population while for none of the methods the boundaries match well the catchment areas as they are defined by the data.

Background: Neonate’s health is intimately linked to maternal health. Yearly approximately 2.8 million neonatal deaths occur worldwide, counting for more than 40 % of all deaths of children less than five years. Over 70 % of these deaths happen during the first week of life (early neonatal mortality), often the first day, and 99% of these deaths occur in low- and middle-income countries with an often low quality of maternal health care services. Aim: To assess societal and household factors, and maternal health care factors delivered in Rwanda, and how these were associated with early neonatal mortality Methods: Cross-sectional data of interviewed mothers to 7726 children between 2010 to 2014, obtained from the 2014–15 Rwanda Demographic and Health Survey, were analyzed in relation to early neonatal mortality using multiple logistic regression. Results: The factors found to be associated with reduced risk of early neonatal mortality were: delivery at a health facility, delivery assisted by a skilled birth attendant, and no low birth weight neonates. After adjustment with socioeconomic and proximate determinants, the same associations were found with delivery at a health facility and no low birth weight neonates. Conclusions: Delivery at a health facility and not to be born of low birth weight were associated with risk reduction of early neonatal mortality. These findings indicate that interventions to strengthen the antenatal health care system and to increase the utilization of already existing health care services are needed, and to educate practicing professional health care workers about early neonatal mortality.

Introduction.

Le Rwanda a connu de nombreuses difficultés au cours des deux dernières décennies :la situation économique précaire, les guerres civiles, le régime politique défaillant, l’instabilité de la sous-région des Grands Lacs, la pandémie du VIH/SIDA ;tous ces bouleversements ont plongé le pays dans l’extrême pauvreté. Au lendemain de la guerre et du génocide, le ministère de la Santé avec l’appui de différents partenaires a canalisé tous ses efforts dans la reconstruction du système de santé. Une meilleure participation communautaire à la gestion et au financement des services de santé était un des objectifs retenus dans cette reconstruction du système de santé. Pour ce faire, le ministère de la Santé, en partenariat avec le PHR (Partnership for health reform) a mis en place des mutuelles de santé « pilote » dans trois districts sanitaires (Byumba, Kabgayi et Kabutare) sur les 39 districts que compte le pays. L’objectif du ministère de la Santé était de généraliser ce système d’assurance maladie après une évaluation de ce projet pilote. Cette initiative de mise en place des mutuelles s’est heurtée au début de sa mise en œuvre à différents problèmes :le faible taux d’adhésion, les problèmes de gestion de la mutuelle, une faible implication des autorités de base dans la sensibilisation, une mauvaise qualité de soins dans certaines formations sanitaires, une utilisation abusive des services par les mutualistes, etc. Malgré ces problèmes d’autres initiatives de mise en place de mutuelles de santé ont vu le jour et continuent de s’implanter ici et là dans les districts sanitaires du pays. Dans le souci de renforcer cette réforme de financement alternatif par les mutuelles de santé, nous avons évalué l’impact des mutuelles sur l’accessibilité aux soins et le renforcement de la participation communautaire aux services de santé et nous avons proposé des voies stratégiques susceptibles d’améliorer le fonctionnement des mutuelles de santé.

Méthodologie

Pour atteindre ces objectifs de recherche, nous avons combiné trois approches différentes :la recherche qualitative qui a permis d’une part, d’analyser le processus de mise en place des mutuelles de santé au Rwanda et d’autre part, de recueillir les opinions des bénéficiaires de services de santé sur ce processus. Ensuite la recherche quantitative nous a permis d’étudier les caractéristiques des membres et non-membres des mutuelles et l’utilisation des services de santé ;enfin la recherche action nous a permis d’expérimenter les axes stratégiques susceptibles de renforcer le développement des mutuelles de santé.

Cette approche méthodologique utilisée tout au long de notre travail de terrain a mené à une « triangulation méthodologique » qui est une combinaison de diverses méthodes de recherche. Dans chacune des méthodes citées, nous avons utilisé une ou plusieurs techniques :analyse de documents, observations et rencontres avec des individus ou des groupes, analyse et compilation des données de routine.

Résultats

Les résultats clés sont synthétisés selon les trois types de recherche que nous avons menés.

1. Processus de mise en place des mutuelles de santé au Rwanda et opinions des bénéficiaires

Dans les trois districts pilotes (Byumba, Kabgayi et Kabutare), les mutuelles de santé prennent en charge le paquet minimum d’activités complet offert au niveau des centres de santé. À l’hôpital de district elles couvrent :la consultation chez un médecin, l’hospitalisation, les accouchements dystociques, les césariennes et la prise en charge du paludisme grave. Pour bénéficier de ces soins une cotisation de 7,9 $ EU ($ des États-Unis) par an pour une famille de sept personnes est demandée, puis 1,5 $ EU par membre additionnel et 5,7 $ EU pour un célibataire. Le ticket modérateur est de 0,3 $ EU pour chaque épisode de maladie et la période d’attente d’un mois avant de bénéficier des avantages du système de mutualisation.

Des entretiens en groupes de concertation (focus groups) nous ont permis de confirmer que la population connaît l’intérêt des mutuelles de santé et qu’elle éprouve des difficultés pour réunir les fonds de cotisations pour adhérer aux mutuelles.

L’analyse critique du processus de mise en place des mutuelles dans les trois districts pilotes nous a permis de conclure que les autorités locales et les leaders d’opinions étaient peu impliqués dans le processus de mise en place des mutuelles et que la sensibilisation était insuffisante. L’appui au processus de mise en place par le PHR a été jugé insuffisant en termes de temps (18 mois) et de formation de cadres locaux qui devraient assurer la poursuite de ce projet. Les défaillances évoquées ont alerté le ministère de la Santé, qui a mis en place un comité de mise en place et de suivi des mutuelles de santé. Depuis ce temps, on observe une émergence des initiatives mutualistes. Le pays compte actuellement 21 % de la population totale qui possède une certaine couverture (partielle ou totale) d’assurance maladie.

2. Caractéristiques des membres et non-membres des mutuelles de santé et utilisation des services de santé par la communauté

Il a été constaté que la répartition selon le sexe, l’état civil et le statut professionnel des membres et non-membres de la mutuelle les caractéristiques ne diffèrent pas significativement entre les adhérents et les non-adhérents à la mutuelle de santé (p > 0,05). Parmi les membres, les proportions des ménages avec revenus élevés sont supérieures à celles observées chez les non-membres (p < 0,001). Quant à la « sélection adverse » que nous avons recherchée dans les deux groupes (membres et non-membres de la mutuelle), nous avons constaté que l’état de morbidité des membres de la mutuelle ne diffère pas de celui des non-membres (p > 0,05). Les personnes qui adhèrent à la mutuelle de santé s’y fidélisent au fil des années (> 80 %) et fréquentent plus les services de santé par rapport aux non-membres (4 à 8 fois plus pour la consultation curative et 1,2 à 4 fois plus pour les accouchements). Les non-membres ont tendance à fréquenter les tradipraticiens et à faire l’automédication. Bien que les mutualistes utilisent plus les services de santé que les non-mutualistes, ils dépensent moins pour les soins.

3. Axes stratégiques développés pour renforcer les mutuelles de santé

Pour mettre en place les stratégies de renforcement des mutuelles de santé, cinq types d’actions dans lesquelles nous avons joué un rôle participatif ont été menés.

D’abord la stratégie initiée pour faire face à l’exclusion sociale :il s’agit de l’entraide communautaire développée dans la commune de Maraba, district sanitaire de Kabutare. Ce système d’entraide, nommée localement ubudehe (qui signifie « travail collectif » en kinyarwanda), assure un appui aux ménages les plus pauvres selon un rythme rotatoire préalablement établi en fonction du niveau de pauvreté.

Une autre stratégie est celle du crédit bancaire accordé à la population pour pouvoir mobiliser d’un seul coup le montant de cotisation. Cette stratégie a été testée dans le district sanitaire de Gakoma. Un effectif de 27 995 personnes, soit 66,1 % du total des membres de la mutuelle de ce district ont souscrit à la mutuelle de santé grâce à ce crédit bancaire.

Les autorités politiques et des leaders d’opinions ont été sensibilisés pour qu’ils s’impliquent dans le processus de mise en place des mutuelles dans leurs zones respectives. Il a été constaté que les leaders d’opinions mobilisent plus rapidement et plus facilement la population pour qu’elle adhère aux mutuelles de santé, que les autorités politiques. Cette capacité de mobiliser la population est faible chez les prestataires de soins.

Certaines mesures ont été proposées et adoptées par les mutuelles de santé pour éviter les risques liés à l’assurance maladie. Il s’agit de l’adhésion par ménage, par groupe d’individu, par association ou par collectivité ;l’exigence d’une période d’attente avant de bénéficier des avantages des mutualistes ;l’instauration du paiement du ticket modérateur pour chaque épisode de maladie ;les supervisions réalisées par les comités de gestion des mutuelles de santé et les équipes cadres de districts ;l’utilisation des médicaments génériques ;le respect de la pyramide sanitaire et l’appui du pouvoir public et/ou partenaire en cas d’épidémie. Ces mesures ont montré leur efficacité dans l’appui à la consolidation des mutuelles de santé.

Enfin, l’« Initiative pour la performance » est la dernière stratégie qui a été développée pour renforcer les mutuelles de santé. Elle consiste à inciter les prestataires à produire plus et à améliorer la qualité de services moyennant une prime qui récompense leur productivité. Les résultats montrent que les prestataires de services ont développé un sens entrepreneurial en changeant leur comportement vis-à-vis de la communauté. Certaines activités du PMA (paquet minimum d’activités) qui n’étaient pas offertes ont démarré dans certains centres de santé (accouchement, stratégies avancées de vaccination, causeries éducatives, etc.). Des ressources supplémentaires ont été accordées aux animateurs de santé, aux accoucheuses traditionnelles et aux membres de comités de santé qui se sont investis plus activement dans les activités des centres de santé. L’intégration des services a été plus renforcée que les années précédentes.

Conclusions

Les mutuelles de santé facilitent la population à accéder aux soins de santé et protègent leurs revenus en cas de maladies.

Le modèle de mise en place des mutuelles de santé au Rwanda est de caractéristique dirigiste :à partir des autorités (politiques, sanitaires ou leaders d’opinions). Il ne serait pas le plus adéquat dans la participation communautaire, mais plutôt adapté à un contexte politique de reconstruction d’un pays.
Doctorat en Santé Publique
info:eu-repo/semantics/nonPublished

Rwanda experienced genocide from April to July 1994 during which over 800,000 people were murdered. Among the far-reaching changes that followed this event among individuals and in society overall, the Rwandan Demographic and Health Surveys (DHS) showed that contraceptive prevalence declined from 13% in 1992 to 4% in 2000 among married women of reproductive age.

This dissertation has two hypotheses concerning Rwandan women's fertility preferences and behavior following the genocide. It is hypothesized that, first, high levels of conflict reduced women's desire for a child or for additional children and second, that women who experienced relatively high levels of conflict were more likely to act on their wish to not have a child or another child by using modern contraceptives than were women who experienced relatively low levels of conflict.

The study's logistic regression dependent (outcome) variables were desire for a or another child and the use of modern contraceptives; the source for these data was the 2000 DHS. Three groups of independent variables were included: socio-demographic variables, also from the 2000 DHS, included age, number of living children, education level, urban/rural residence and socio-economic status; availability of family planning services, assessed using women's perception of distance as a barrier to obtaining health care for themselves, from the 2000 DHS, and quality of health services, assessed with data from the 2001 Service Provision Assessment; and experience of conflict, measured as the percentage of the 1994 commune populations that resided in refugee camps in 1995. Communes were considered `high migration' if 10 percent or more of their populations migrated to camps and `low migration' if less than 10 percent of their populations migrated to camps. Women who lived in high migration communes were considered to have relatively high experience of conflict and those who lived in low migration communes were consider dot have relatively low experience of conflict.

Analysis showed that residents of high migration communes were significantly less likely to want a or another child as compared to residents of low migration communes (OR = .74); it appeared that the social environment of high migration had a dampening effect on desire for children. The analysis also showed that residents of high migration communes were significantly less likely to use a modern contraceptive method than were those of low migration communes (OR = .57), even though they were less likely to want a or another child and even when family planning services were reasonably available.

The reasons for these results are unclear, and many factors may contribute. The generalized trauma experienced by the population may have had a numbing effect, in which taking action in any domain was difficult. Women may have felt pressured by society to have children as the society emerged from war, despite their own preferences. The population may also have distrusted government health facilities—the only source of services for most—in light of the interactions with officials during and after the genocide. However, another set of reasons specific to women and women's health may also have influenced the findings. There is a pervasive social stigma around reproductive health; these services have generally lagged behind other primary health care components. Moreover, rape was used as a weapon of war in the genocide; these experiences may have reduced women's willingness to seek reproductive health services specifically. Finally, the Rwandan genocide and its preparation were decidedly misogynistic; this pervasive dehumanization may have made it particularly difficult for women to seek care for their sexual and reproductive health needs and desires. This complex personal, social, physical and political context may explain why Rwandan women who may not have wanted a child or additional children nonetheless did not consistently act on their desires in the years following the 1994 genocide.

The dissertation includes a series of essays providing the author's personal perspective on working in Rwanda in the 1980s and 1990s and being present in the country at the start of the genocide in April 1994.

Physical inactivity has become a global health concern and is among the 10 leading causes of death and disability. This has led to increased concern for chronic diseases of lifestyle (CDL). 
Studies have revealed that regular physical activity is effective in combating several CDL such as cardiovascular disease, diabetes, cancer, hypertension and obesity. Physiotherapists are in a 
position to combat inactivity and effectively promote physical activity to their clients. Studies however have shown that participation in physical activity among physiotherapists could have an 
impact on the promotion of physical activity and their health practices. This study therefore sought to establish the relationship between physical activity levels of physiotherapists and their 
physical 
activity promotion strategies and barriers to promoting physical activity. Sequential Mixed Method Design was used in this study. Data was collected by means of a self administered 
questionnaire and a total of 92 physiotherapists voluntarily answered the questionnaire. A focus group discussion comprising of 10 purposively selected physiotherapists was conducted. The 
questionnaire assessed physical activity levels 
and physical activity promoting strategies of the participants while the focus groupdiscussion looked at the barriers to promoting physical 
activity. The Statistical Packages for Social Sciences (SPSS) version 18 was used for data capturing and analysis. Descriptive statistics were employed to summarize demographic information 
as means, standard deviation, frequencies and percentages. Inferential statistics (chi-square) was used to test the associations between different categorical variables (p<
0.05). For the qualitative data, focus group discussions were used to collect data. Tape recorded interviews were transcribed verbatim, field notes typed, sorting and arranging data was done and themes 
 
were generated. Thematic analysis was then done under the generated themes. Ethical issues pertaining to informed consent, anonymity, confidentiality and the right to withdraw from the 
study were respected in this current study. The findings in the current study revealed that a big number of the participants were physical active both at work and recreation domains. However, 
there was no statistically significant association between physical activity and the demographicvariables. The results in this study revealed that the majority of participants were good 
physical activity promoting practices, although there was no significant association between physical activity levels and the physical activity promoting practices. The finding in this study revealed that discussing physical 
activity and giving out information regarding physical activity to their clients were the most common methods used in promoting physical activity. However, participants also highlighted barriers they 
ace in promotion of physical activity such as policies on physical activity, cultural influence, nature of work, time management as well as environmental barriers. The study demonstrates the 
need for all stakeholders to come up with solutions to break the barriers to promotion of physical activity. In return it will bring about enormous health 
benefits to the general population.

Compliance with hand hygiene is widely recognized as the most important factor in preventing transmission of infection to patients in healthcare settings (Haas and Larson, 2007). Hand hygiene dramatically decreases the potential pathogens on hands and is considered the first measure for decreasing the risk of transmitting organisms to patients, healthcare professionals, and family members. Noncompliance with hand hygiene practices has been shown to increase healthcare-associated infections, costing hospitals $35.7-$45 billion each year (Centers for Disease Control and Prevention [CDC], 2012). Education about hand hygiene starts in school and should transfer into the real world of nursing. The purpose of this research is to determine how student nurses in a baccalaureate nursing program in northeastern Tennessee perceive hand hygiene and the importance of conducting the act of hand washing. Students who do not perceive it as important, or do not have the correct information, are unlikely to use principles of good hand hygiene in their practice. Few studies were found assessing nursing school students’ perception of the importance of hand hygiene.

Many countries are looking to health insurance to improve access to medical care for low- income groups and to raise additional revenues for a depleted health sector. In Rwanda, concerns about a sharp drop in demand for medical services after the re-introduction of user fees in 1996, motivated the government to design and pilot-test micro-health insurance (MHI) in three districts. This thesis compares the performance of the current Rwandan MHI with the user fee system and against principles of egalitarian equity and sustainability. It draws from the economic and social literature related to health insurance, equity and sustainability; and uses cross-sectional routine and survey data collected on insured and uninsured population groups from health centres, MHI, households, patients and focus groups during the Rwandan pilot phase (7/1998-6/2000). It aims to contribute to the research on equity and sustainability in health financing and utilisation by evaluating and comparing the implications of MHI and of user fees for households and on the health sector. The analysis comprises three main components. First, it examines the demand for health insurance in a binary choice model. Second, following egalitarian equity principles and the minimum standard approach, it evaluates the impact of utilisation and financing of health care on the financial situation of insured and uninsured households. Third, it uses an econometric cost function that allows identification of payer-specific outputs to analyse and compare the cost and efficiency implications of MHI with capitation payment versus user fees in health centres, in order to test the hypothesis that providers adjust the treatment intensity to the expected payment mechanisms. Based on findings, a MHI insurance design is derived to scale up risk-pooling and improve equity and sustainability in the district health system.

Magister Public Health - MPH
Background: Adequate human resources for health play a crucial role in improving access to services and quality of care. Human resources for health are often inequitably distributed between rural and urban areas within countries. In Rwanda, almost 88% of physicians and 58% of nurses in the country work in urban areas, despite the fact that 82% of the population lives in rural areas. Kabaya is located in a remote rural area in Ngororero District; its health facilities consist of one hospital and four health centers. Living and working conditions are poor for health workers. This results in constant migration out of health workers, which has negative impacts on service delivery and quality of care provided to the population. Aim and Objectives: This study aimed to assess factors that influence the intention to stay in Kabaya amongst health workers currently in Kabaya's health facilities. The specific objectives were to analyze the associations between the following factors and intention to stay among health workers in Kabaya: socio-demographic and job characteristics; working and living conditions; and financial and non-financial incentives. Study design: An analytical, cross-sectional survey of all health workers from five facilities in Kabaya was conducted. Methods: A self-administered questionnaire, adapted from one used in a study in Uganda (Hagopian, Zuyderduin, Kyobutungi & Yunkella, 2006), was used to collect data. Data were entered in Epi- Info 3.4 and analyzed using SPSS 16.0. Descriptive analyses and inferential statistics (Chisquare,Fisher‟s Exact) were done to test for associations with the main outcome, intention to stay. Results Out of 155 employees working in Kabaya‟s health facilities, 111 (72%) accepted to participate in the study. Of the 111 respondents, 34 (31%) indicated they intended to stay working in Kabaya indefinitely. Intention to stay (bivariate analysis) was associated with:  employment category (p=0.001) and age (p<0.001);  rural background - born in Kabaya (p<0.001); and born (p=0.001), grew up (p=0.001) and studied in a rural area (p<0.001); good quality supervision - encouraging employee development (p=0.029), caring for the employee as a person (p=0.011), and competent and committed facility managers(p=0.039);  presence of workplace friends (p<0.001);  conducive work and living environments - manageable workloads (p<0.001); good infrastructure (p<0.001); access to safe and clean water at work (p<0.001); adequate housing at home (p<0.001); having time to take lunch at work (p=0.001); access to adequate transportation to work (p=0.004); adequate shopping and entertainment(p=0.001);  adequate incentives - sufficient salary (p<0.001); recognition for doing a good work(p<0.001); and adequate training (p<0.001). The small study sample precluded multi-variate analyses and it was therefore not possible to control for potential confounders such as age, sex and profession in the analysis of workplace factors. Conclusions: Intention to stay in Kabaya appears to be influenced by a complex set of factors that include: individual (age, profession, rural background), workplace, human, social, career and salaryrelated factors. Promoting retention in Kabaya‟s health facilities requires multi-faceted interventions, without which the majority of the employees are likely to continue to migrate away from the area.

From late 2020 to early 2021, the Sanitation Learning Hub (SLH) collaborated with local government actors and development partners from three sub-national areas to explore ways of increasing local government leadership and prioritisation of sanitation and hygiene (S&H) to drive progress towards area-wide S&H. For some time, local government leadership has been recognised as key to ensuring sustainability and scale and it is an important component of the emerging use of systems strengthening approaches in the S&H sector. It is hoped that this work will provide practical experiences to contribute to this thinking. Case studies were developed to capture local government and development partners’ experiences supporting sub-national governments increase their leadership and prioritisation of S&H in Siaya County (Kenya, with UNICEF), Nyamagabe District (Rwanda, with WaterAid) and Moyo District (Uganda, with WSSCC), all of which have seen progress in recent years. The cases were then explored through three online workshops with staff from the local governments, central government ministries and development partners involved to review experiences and identify levers and blockages to change. This document presents key findings from this process.

The Promotion and Practice Handwashing Kit (PPHWK), a robust, user-friendly handwashing station, and Mum’s Magic Hands (MMH), a creative hygiene promotion strategy, were evaluated in a clustered randomized controlled trial in Kyaka II refugee settlement in Uganda. The trial evaluated whether their provision increased handwashing with soap practice among residents, with a focus on three community intervention arms and two school-based intervention arms. The findings outlined in this report suggest that exposure to both the PPHWK and MMH increased hygiene knowledge and handwashing behaviour with soap, and improved health outcomes. Intervention households also preferred the PPHWK over existing handwashing stations, typically a basic bucket with a tap.

Covid-19 and the response and mitigation efforts taken to contain the virus have triggered a global crisis impacting on all aspects of life. The impact of the Covid-19 pandemic for forcibly displaced persons (refugees, internally displaced persons and asylum seekers) extends beyond its health impacts and includes serious socioeconomic and protection impacts. This rapid review focuses on the available evidence of the socioeconomic impacts of the crisis on forcibly displaced persons, with a focus where possible and relevant on examples from countries of interest to the Covid Collective programme: Afghanistan, Bangladesh, Ghana, Iraq, Kenya, Malawi, Pakistan, Rwanda, South Sudan, Syria, Uganda, Yemen, Zambia and Zimbabwe.

Since first appearing at the end of 2019, the novel coronavirus disease (COVID-19) has spread at a pace and scale not seen before. On 11 March 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. A rapid response was called for, and actors across the globe worked quickly to develop sets of preventative measures to contain the disease. One mode of transmission identified early on in the crisis was via surfaces and objects (fomites) (Howard et al. 2020). To combat this, hand hygiene was put forward as a key preventative measure and heralded as ‘the first line of defence against the disease’ (World Bank 2020). What followed was an unprecedented global focus on handwashing with soap. Health messages on how germs spread, the critical times at which hands should be washed, and methods for correct handwashing were shared (Centers for Disease Control and Prevention 2020). Political leaders around the world promoted handwashing and urged people to adopt the practice to protect against the coronavirus. The primary and secondary impacts of COVID-19 have affected people and industries in a variety of different ways. For the WASH sector, the centring of handwashing in the pandemic response has led to a sudden spike in hygiene activity. This SLH Rapid Topic Review takes stock of some of the cross-cutting challenges the sector has been facing during this period and explores the adaptations that have been made in response. It then looks forwards, thinking through what lies ahead for the sector, and considers the learning priorities for the next steps.

Over the past three years, the Ishraq program in the villages of northern El-Minya, Egypt, grew from a novel idea into a vibrant reality. In the process, approximately 300 rural girls have participated in a life-transforming chance to learn, play, and grow into productive members of their local communities. Currently other villages—and soon other governorates—are joining the Ishraq network. Ishraq is a mixture of literacy, life-skills training, and—for girls who have been sheltered in domestic situations of poverty and isolation—a chance to play sports and games with other girls their age and develop a sense of self-worth and mastery; the program reinforces the lessons they receive in life-skills classes about hygiene, nutrition, and healthy living. This guide to the sports and games component of the program is geared to the needs of disadvantaged adolescent girls. It is intended for those in the development community interested in the potential of sports to enhance the overall impact of adolescent programs. Sports can be combined with other program components to give girls a more active experience, whether the primary focus is reproductive health, literacy, or livelihood skills.

The Population Council initiated its work on adolescents in the mid-1990s. At that time, those advocating greater attention to adolescent issues were concerned about adolescent fertility—particularly outside of marriage—and adolescent “risk-taking” behavior. As an international scientific organization with its mandate centered around the needs of developing countries, the Council sought a more nuanced and context-specific understanding of the problems confronting adolescents in the developing world. In working with colleagues inside and outside the Council, it became clear that information on adolescents, and the way data are organized, were limiting the ability to understand the diversity of their experiences or to develop programs to address that diversity. In the absence of data, many adolescent policies were implicitly based on the premise that the lives of adolescents in developing countries were like those of adolescents in Western countries. In fact, significant numbers of young people in the West do not fit this description, and even larger groups within the developing countries. The Council created tables to more clearly describe the diversity of the adolescent experience by drawing on Rwanda Demographic and Health Survey data. The tables, presented in this report, are intended to be used as a basis for developing programs.