Understanding needs and solutions to promote healthy ageing and reduce multimorbidity in Rwanda: A protocol paper
Authors: Amberbir Alemayehu , Cyuzuzo Callixte , Boah Michael , Uwinkindi Francois , Kalinda Chester , Yohannes Tsion , Isano Sandra , Ojiambo Robert , Greig Carolyn , Davies Justine , Hirschhorn Lisa R 
Published: December 2024

AbstractBackgroundAgeing 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 World Health Organization. However, there are limited data available to inform prioritisation of interventions, particularly for countries in sub-Saharan Africa.MethodsThis study has five interlinked work packages (WPs), designed to understand 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 (NCD) 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 voice of older people, we will explore the quality of healthcare as experienced by them using in-depth interviews (IDIs). In Fourth, we will synthesise data using mixed methods to understand barriers to access to quality of care in older agebased on a 3-delays framework (seeking, reaching, and receiving quality health care). Finally, the project will culminate in a stakeholder workshop to ensure results are contextually appropriate and disseminated, and gaps identified are prioritized to design novel interventions to promote healthy ageing in Rwanda and the region.DiscussionThis study will deliver impactful research by using multiple methodologies and working with in-country partners to develop a deep knowledge and understanding of health care 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 (LMICs) during this Decade of Healthy Ageing and beyond.Strengths and limitations of this studyStrengths of this study include our cross-disciplinary mixed methods health systems research, implementation research and a large population-based survey design;Our population-based study will cover over 127 villages in the city of Kigali (predominantly urban) and Burera district in Northern part of Rwanda (predominantly rural) covering a total sample size of 4280 increasing external validity of the study;It will provide, to our knowledge for the first time, a picture of public-sector health facility care seeking behaviors and health utilization experiences among older individuals in urban and rural Rwanda;Further strengths include our stakeholders’ involvement and engagement which will lead to strategies for translation of the findings in to practice and impact;Limitations of this study will include the cross-sectional nature of the study limiting our ability to assess a cause-and-effect relationship. Moreover, some of the chronic conditions (heart and respiratory disease, high cholesterol) and HIV in the study will rely on self-report of a diagnosis;Our study is further limited in that we will not collect all dimensions of the health systems responsiveness domains. Moreover, the study will not be representative of health centers and health care workers in private or higher-level health care facilities in Rwanda.