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Item Lowering hospital walls to achieve health equity(BMJ Publishing Group Ltd, 2018-09-20) Matheson A; Bourke C; Verhoeven A; Khan MI; Nkunda D; Dahar Z; Ellison-Loschmann LHospitals have evolved to become integral and dominant components of health systems, although their functions, organisation, size, degree of centralisation, and resourcing varies across countries. Despite this diversity, hospitals are generally focused on providing services for sick people rather than prevention. Although many have shown the capacity to quickly adopt new technologies, especially for diagnosing and managing illness, achieving institutional change to tackle the systemic causes of health inequities has proved much more difficult. We argue that the actions of hospitals contribute to health inequities. This is important given that hospitals hold an inordinate share of power, resources, and influence within health and community systems—while primary care and prevention are consistently undervalued and underfunded. We draw on four opportunistically selected country case examples to show the role that hospitals can play in overcoming systemic barriers to health equity. Each example highlights health sector actions taken for particular population groups: women and children in Pakistan and Rwanda and the indigenous peoples of Australia and New Zealand.Item Predictors for achieving adequate antenatal care visits during pregnancy: a cross-sectional study in rural Northwest Rwanda(BioMed Central Ltd, 2023-01-26) Dusingizimana T; Ramilan T; Weber JL; Iversen PO; Mugabowindekwe M; Ahishakiye J; Brough LBACKGROUND: Inadequate antenatal care (ANC) in low-income countries has been identified as a risk factor for poor pregnancy outcome. While many countries, including Rwanda, have near universal ANC coverage, a significant proportion of pregnant women do not achieve the recommended regimen of four ANC visits. The present study aimed to explore the factors associated with achieving the recommendation, with an emphasis on the distance from household to health facilities. METHODS: A geo-referenced cross-sectional study was conducted in Rutsiro district, Western province of Rwanda with 360 randomly selected women. Multiple logistic regression analysis including adjusted odd ratio (aOR) were performed to identify factors associated with achieving the recommended four ANC visits. RESULTS: The majority (65.3%) of women had less than four ANC visits during pregnancy. We found a significant and negative association between distance from household to health facility and achieving the recommended four ANC visits. As the distance increased by 1 km, the odds of achieving the four ANC visits decreased by 19% (aOR = 0.81, P = 0.024). The odds of achieving the recommended four ANC visits were nearly two times higher among mothers with secondary education compared with mothers with primary education or less (aOR = 1.90, P = 0.038). In addition, mothers who responded that their household members always seek health care when necessary had 1.7 times higher odds of achieving four ANC visits compared with those who responded as unable to seek health care (aOR = 1.7, P = 0.041). Furthermore, mothers from poor households had 2.1 times lower odds of achieving four ANC visits than mothers from slightly better-off households (aOR = 2.1, P = 0.028). CONCLUSIONS: Findings from the present study suggest that, in Rutsiro district, travel distance to health facility, coupled with socio-economic constraints, including low education and poverty can make it difficult for pregnant women to achieve the recommended ANC regimen. Innovative strategies are needed to decrease distance by bringing ANC services closer to pregnant women and to enhance ANC seeking behaviour. Interventions should also focus on supporting women to attain at least secondary education level as well as to improve the household socioeconomic status of pregnant women, with a particular focus on women from poor households.Item A Mixed-Methods Study of Factors Influencing Access to and Use of Micronutrient Powders in Rwanda(Johns Hopkins Center for Communication Programs, 2021-06-30) Dusingizimana T; Weber JL; Ramilan T; Iversen PO; Brough LThe World Health Organization recommends point-of-use fortification with multiple micronutrients powder (MNP) for foods consumed by children aged 6-23 months in populations where anemia prevalence among children under 2 years or under 5 years of age is 20% or higher. In Rwanda, anemia affects 37% of children under 5 years. The MNP program was implemented to address anemia, but research on factors affecting the implementation of the MNP program is limited. We conducted a mixed-methods study to examine the factors influencing access to and use of MNP among mothers (N=379) in Rutsiro district, northwest Rwanda. Inductive content analysis was used for qualitative data. Logistic regression analysis was used to determine factors associated with the use of MNP. Qualitative results indicated that the unavailability of MNP supplies and distribution issues were major barriers to accessing MNP. Factors influencing the use of MNP included mothers' perceptions of side effects and health benefits of MNP, as well as inappropriate complementary feeding practices. Mothers of older children (aged 12-23 months) were more likely to use MNP than those of younger children (aged 6-11 months) (adjusted odds ratio [aOR]=3.63, P<.001). Mothers whose children participated in the supplementary food program were nearly 3 times more likely to use MNP than those whose children had never participated in the program (aOR=2.84, P=.001). Increasing household hunger score was significantly associated with lower odds of using MNP (aOR=0.80, P=.038). Mechanisms to monitor MNP supply and program implementation need to be strengthened to ensure mothers have access to the product. MNP program implementers should address gaps in complementary feeding practices and ensure mothers have access to adequate complementary foods. L'Organisation Mondiale de la Santé recommande l'enrichissement de l'alimentation à domicile (enrichissement sur le point d'utilisation) à l'aide des poudres de micronutriments multiples (PMN) pour les aliments consommés par les enfants âgés de 6 à 23 mois dans les populations où la prévalence de l'anémie chez les enfants de moins de 2 ans ou 5 ans est de 20% ou plus. Au Rwanda, l'anémie touche 37% des enfants de moins de 5 ans et le programme de PMN a été mis en œuvre pour lutter contre l'anémie. Cependant, la recherche sur les facteurs qui affectent la mise en œuvre du programme de PMN est limitée. Nous avons mené une étude par méthodes mixtes pour examiner les facteurs qui influencent l'accès des mères (n=379) à la PMN et son utilisation dans le district de Rutsiro, au nord-ouest du Rwanda. L'analyse du contenu inductif a été utilisée pour les données qualitatives. Pour déterminer les facteurs associés à l'utilisation des PMN, une régression logistique a été utilisée. Les résultats qualitatifs ont indiqué que l'indisponibilité des approvisionnements en PMN et les problèmes de distribution constituaient des obstacles majeurs à l'accès à la PMN. Les facteurs qui influencent l'utilisation des PMN comprenaient les perceptions, chez les mères, des effets secondaires et des avantages des PMN pour la santé, ainsi que des pratiques d'alimentation complémentaire inappropriées. Les mères d'enfants plus âgés (12 à 23 mois) étaient plus susceptibles d'utiliser la PMN que celles d'enfants plus jeunes (6 à 11 mois) (odds ratio ajusté [ORA]=3,63, P<0,001). Les mères des enfants qui avaient participé au programme d'alimentation complémentaire étaient près de 3 fois plus susceptibles d'utiliser la PMN que celles des enfants qui n'avaient jamais participé au programme (ORA=2,84, P=0,001). L'augmentation du score de faim dans les ménages était significativement associée à des chances plus faibles d'utiliser la PMN (ORA=0,80, P=0,038). Les mécanismes de suivi de l'approvisionnement en PMN et de la mise en œuvre du programme doivent être renforcés pour s'assurer que les mères ont accès au produit. Les responsables de la mise en œuvre du programme de PMN devraient combler les lacunes au niveau des pratiques d'alimentation complémentaire et veiller à ce que les mères aient accès à des aliments complémentaires adéquats.Item An investigation of factors associated with child stunting in northwest Rwanda : the role of care practices related to child feeding and health : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science, College of Sciences, Massey University, Palmerston North, New Zealand(Massey University, 2021) Dusingizimana, TheogeneBackground: Stunting (height-for-age z-score < - 2 SD from the median of the WHO growth standards and a marker of chronic undernutrition) among children under 5 years is a public health challenge particularly in low- and middle-income countries, including Rwanda. Understanding the contributing factors is key for guiding future interventions and policies to address stunting. Objective: This thesis aimed to investigate the factors associated with stunting among children aged 6–23 months of age in Rutsiro district, Rwanda, including the relationship between stunting and care practices related to child feeding and health. Methods: A mixed-methods approach was used, consisting of an initial qualitative study followed by a cross-sectional survey. In the qualitative study, in-depth interviews with mothers (n= 24) were conducted to explore infant and young child feeding (IYCF) practices - [Study 1]. The qualitative study informed the development of a questionnaire which was used to collected data in a cross-sectional survey. In the survey, quantitative data at child-, maternal-, and household-level were obtained from 400 mother-child pairs. Child’s anthropometric measurements were collected and used to determine child height-for-age z-scores (HAZ), which were used to define stunting. Data on infant and young child feeding (IYCF) and health practices were collected and used to construct an infant and child feeding practices index (ICFI) and a health practices index (HPI), respectively. Qualitative data on the use of multiple micronutrients powder (MNP) during complementary feeding were also collected during the survey. Multiple linear regression analysis was used to examine the association between HAZ and factors, including demographics, ICFI and HPI - [Study 2]. Content analysis and logistic regression analysis were carried out on qualitative and quantitative data, respectively, to examine factors related to access and use of multiple micronutrients powder (MNP) - [Study 3]. Results: Mothers described two different food classification systems, based on modern nutrition knowledge about foods and on traditional beliefs about appropriateness of foods for young children. The traditional beliefs about foods, and the inability to recognize undernutrition/stunting, coupled with limited economic access to foods determines what foods children consume, and result in suboptimal IYCF practices, including limited diversity and amount of foods, and limited use of MNP. Results from the cross-sectional survey showed that 38% of the children were stunted (HAZ < ‒ 2 SD). Maternal height, infant birth weight, and ICFI were positively associated with child HAZ. Conversely, child’s age, sex (male), altitude, diarrhoea and upper respiratory infections in the previous 4 weeks were negatively associated with HAZ. No significant relationship was observed between HPI, household wealth index and child HAZ. Results also indicated that, compared with mothers of young children (6–11 months), mothers of older children (12–24 months) had significantly higher odds of using of MNP during complementary feeding. Similarly, mothers whose children participated in the food supplemental programme had significantly higher odds of using MNP, whereas increasing household hunger score was significantly associated with lower odds of using MNP. Conclusions: In this setting, IYCF practices are suboptimal, and are associated with stunting. A tailored educational intervention designed to address existing beliefs and perceptions related to child feeding is required. Findings also indicate the need to facilitate mothers’ implementation of appropriate practices through (child-sensitive) programmes that can enhance mothers’ economic conditions and access to foods. The range of factors found to be associated with child HAZ suggests that a multi-sectoral approach is required to address stunting. Such approach should include interventions to improve health and nutrition of women before and during pregnancy to prevent prenatal growth restriction. Postnatally, interventions to promote optimal IYCF practices, particularly breast-feeding practices and dietary diversity should be coupled with measures to control infections.Item Healing from the horror of war : a study of a post-conflict psychosocial program for refugees in Uganda : a research report presented in partial fulfilment of the requirements for the degree of Master of International Development at Massey University, Palmerston North, New Zealand(Massey University, 2018) Manson, TimUganda, a landlocked African nation of 41 million people, currently hosts 1.1 million refugees from surrounding nations including South Sudan, the Democratic Republic of the Congo (DRC) and Rwanda. Many of these refugees have suffered significant psychological trauma as a result of their conflict experiences and through the process of fleeing from their homes and communities. Tutapona is a non-profit organisation that provides group based psychosocial trauma rehabilitation support among war affected populations. This research report examines the effectiveness of the ‘Grow’ program at empowering refugees. The study was carried out in Rwamwanja Refugee Settlement in Western Uganda, which is home to 64,000 people from the DRC. Four refugees who had attended Tutapona’s Grow program were interviewed in depth about their experience and subsequent decisions to ascertain the extent to which empowerment had taken place. The research report concludes that Tutapona’s Grow program has achieved a high degree of success at empowering refugees, especially on the individual and relational levels. More broadly, it suggests that psychosocial interventions in post- conflict settings should be more highly prioritized by humanitarian and development actors.Item Rebuilding communities : a case study of empowerment in post-conflict Rwanda : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Development Studies at Massey University(Massey University, 2009) Parsons, AnnaEmpowerment became a popular concept in the 1990s, so popular that some believe the concept has lost its impact. This thesis uses the empowerment levels of; personal, relational and community, to investigate a psychosocial intervention in the post-conflict environment. The post-conflict environment is one that is disempowering for both men and women. Rwanda, one of the most complicated and devastated post-conflict situations seen since World War II, is the location of the World Vision intervention examined in this thesis. World Vision's Personal Development Workshop aims to provide a safe environment where people can process their experiences of the genocide. They use lectures, individual exercises and small group discussions to cover the topics of understanding the grief process, dealing with emotions and the concept of forgiveness. The thesis concludes that both male and female participants of the Personal Development Workshops have been empowered at all three levels. It shows the benefit of using the empowerment approach in the community context and suggests that consideration of psychosocial interventions is crucial in post-conflict settings. The need for such interventions to be continued for many years after the conflict has ended is also identified.