Age friendly services provision for older adults in Rwanda’s primary healthcare system: An analysis of facility readiness and healthcare providers’ perspectives

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This study examined primary healthcare facilities and providers’ readiness in delivering AFHS in rural and urban districts in Rwanda. Methods The study included 24 PHFs and 180 providers in the Burera district in the northern province and in Nyarugenge, Kicukiro, and Gasabo districts across the city of Kigali, using surveys developed based on the WHO’s age-friendly toolkit. A facility readiness survey gathered information on training, service availability, health assessments, and facility design. A provider survey captured providers’ demographics and knowledge, attitudes, and practices about care for older people and AFHS. Data were collected using REDCap and statistically analyzed using descriptive statistics and multiple linear regression analysis. Results The study found that all facilities were inadequately prepared to provide AFHS. Only 12.5% of facilities had staff trained in geriatric care, 8% had a worker to help older adults, and 4% had a special consultation area for them. Furthermore, no facilities provided home health services or budget or cost reductions for older patients. All facilities had glucometers, thermometers, and blood pressure machines, but some facilities lacked infrastructure features such as grab bars (13%) and accessible toilets (46%). The majority of the surveyed facilities had processes to identify older adult conditions; however, resources were limited. Two-thirds of the facilities did not assess hearing ability, while more (71%) assessed vision. Only 25% had process to screen for suspected elder abuse. Over half of providers (59%) had experience caring for older adults at the facilities and 72% had experience caring for an older family member. Most of the providers (67%) had heard about healthy ageing, but only 33% were familiar with AFHS. Just 11% of providers had received formal training on older adult care, and few (12%) were trained on older people’s specific needs. Conclusions Primary healthcare facilities and their providers in Rwanda are not yet prepared to deliver effective AFHS. Improvements are needed in infrastructure, human resources, training, health financing, and service delivery. Facility readiness age-friendly healthcare services knowledge attitudes and practices ageing primary care Rwanda Figures Figure 1 Figure 2 Figure 3 Background The global population of older people is expected to be more than double by 2050, with survival to older ages increasing worldwide and in the low- and middle-income countries including Rwanda( 1 ). Associated with ageing, globally has been a rise in both noncommunicable diseases (NCDs) and conditions of older age( 2 , 3 ). These changing demographics highlight the need for primary care and public health interventions to promote healthy ageing, reduce mortality and morbidity related to NCDs, and strengthen health systems through improved infrastructure, and human resources. Primary healthcare is a cornerstone for effective and quality universal health coverage among the ageing population( 4 ). In workshops done in rural and urban Rwanda with older people and other stakeholders, access to healthcare for older people was identified as a priority issue( 5 ). Currently, weak and ineffective implementation of age-friendly healthcare services (AFHS) at primary healthcare facilities (PHFs) has resulted in enormous unmet needs for older adults, with significant gaps in capacity, access, and delivery found in Uganda and Nigeria( 6 , 7 ). These gaps in readiness include insufficient trained staff, infrastructure, and equipment. In Uganda, a study that assessed the readiness of the facilities highlighted low readiness in leadership, financing, human resources and health management information systems, equipment, and other necessary commodities for geriatric care( 8 ). Other research found that there was a lack of geriatric centers and training institutions( 9 , 10 ). Similar results were found in Nigeria including inadequately prepared systems and poor facility designs in Lagos, and challenges in screening common conditions for older individuals in Lagos, Nigeria( 4 , 11 ). To address unmet needs of older adults, the WHO has released an age-friendly healthcare centres toolkit with the purpose of improving health services delivery at the facilities and train providers on the specific needs of older persons ( 12 ). Targeted recommendations focused on information and communication, education and training, healthcare management systems, and physical environment. Improving these target areas is expected to reduce conditions associated with old age, older people's admission rates at facilities, and contribute to timely and quality healthcare provision( 13 ). The 2022 Rwanda Population and Housing Census found that 21% of Rwanda’s population is aged 40 years and above, and 6.5% aged 60 years and above( 14 ). These numbers represent over 2.7 million individuals who would benefit from AFHS. Given the current and future population of older adults, there is a need to conduct interventions on how to promote healthy ageing and reduce NCD-associated multimorbidity in people of advanced ages( 15 ). The Government of Rwanda, through the Ministry of Local Government in consultation with other ministries, civil societies, and the Rwandan elders’ advisory forum, has established a National Older Persons’ Policy with the aim of empowering, supporting, and promoting the inclusion of older persons in all aspect of Rwandan society. A key strategy includes securing an environment in which older persons are ensured with dignity, rights to health, secured lives and responsibilities( 16 ). The Rwandan health system’s readiness to meet the needs for older persons is not well documented. To support this need and to address a critical gap in understanding the readiness of health facilities and providers to deliver effective, age-friendly care in Rwanda, we measured the readiness of the PHFs in urban and rural settings to deliver effective AFHS to older people in Rwanda and the knowledge, attitudes, and experience of primary care providers in providing prevention and care for this growing population. Methods Study setting Rwanda is a low-income country located in East Africa, with a population of about 13 million. It has five provinces and has adopted a decentralized healthcare system with 30 district health offices responsible for health services provision in their respective zones( 17 ). Rwanda has five national referral hospitals, 42 district hospitals, 500 health centres providing primary healthcare, and 1700 health posts. This study was conducted in three administrative districts (Gasabo, Nyarugenge, and Kicukiro) in the City of Kigali (urban site) and Burera district (rural site) in the Northern province. The city of Kigali has 36 health centres (16 in Gasabo, six in Nyarugenge, and 14 in Kicukiro) that serve a population of more than 1.7 million; Burera district has 19 health centres serving 387,729 people( 14 ). Study design, participants, and sample size This cross-sectional study included a total of 24 primary healthcare centres located in both rural and urban settings of Rwanda. A simple random sampling technique was employed with the sample size limited by study resources to choose 12 of the 36 centres across the three districts in the city of Kigali, and 12 of the 19 in Burera district. One leader at every selected healthcare facility completed the facility readiness survey and at least seven consented healthcare providers per facility who were providing care and present at the time of the survey answered the Knowledge, Attitudes, and Practices (KAP) survey. Eligible healthcare workers included medical doctors, nurses, midwives, laboratory technicians, and community health workers. Survey tools and data collection procedures The details of the methods and conduct of this study were reported elsewhere( 18 ). In brief, tools for the facility readiness and AFHS delivery KAP surveys were adapted from the WHO age-friendly toolkit and used previously in the studies conducted in other lower- and middle-income countries( 4 , 8 , 12 , 19 ). The facility survey focused on geriatric care training and service delivery, availability of clinical services and health assessment for older persons, facility design, user friendly health centre and physical environment, and facility health management information system(Additional file1a). The KAP survey instrument captured data on healthcare workers, their demographic information, and professional experiences. The KAP survey tool had 37 questions that assessed knowledge, eight for attitudes, and 30 for practices (Additional file 1b). The survey tools were translated into Kinyarwanda, back translated, and checked for correctness. The data collection tools were pilot tested at two primary healthcare centres not included in the study, one in Burera district and another in the city of Kigali. They were further revised based on feedback from participants and research assistants to make them more relevant to the Rwandan health system context. Data on facility readiness and KAP were collected from June to July 2024 using a web-based version of the REDCap software platform. Eleven trained data collectors collected data through direct observation and structured in-person survey administration. Tape measures were used to measure the width of the facility doors and the main entrance to the facilities. Data management and analysis Data quality checks were conducted throughout the study, and the study used descriptive statistics including frequencies or percents for categorical variables and median and interquartile range for continuous variables. For facility readiness, a descriptive analysis was performed. For healthcare providers, the primary outcomes were KAP scores. The knowledge of ageing and AFHS was measured as yes versus no and correct versus incorrect based on WHO guidelines( 20 ). “Yes,” and correct responses were scored as 1, incorrect, and “no” responses as 0. Questions on attitudes towards age-friendly services were scored using a four-point Likert scale as strongly agree, agree, disagree and strongly disagree scored 1, 0.75, 0.5 and 0, respectively. Practice of AFHS were measured using a three-point Likert scale (always, sometimes, and never scored 1, 0.5, and 0, respectively) ( 4 ) (Additional file 2). Multiple linear regression analysis was used to measure the association between participants’ characteristics and KAP scores of AFHS. A confidence interval of 95% was employed and a p -value < 0.05 was considered statistically significant. The Stata/SE 13.0 (StataCorp LP, College Station, Texas, USA) was used for all statistical analysis. Results Geriatric care training and service delivery None of the 24 facilities had all the needed components for delivering AFHS. There were significant facility gaps in delivering home health services, training staff, health financing, and specialized personnel to help older adults. For example, only 12.5% had staff trained on the care for older adults; 8% had a designated health worker to help them and none of the facilities delivered home health services (Fig. 1 and Additional file 3). Figure 1. Health facility provisions for older adult care Availability of equipment, clinical services, and health assessment for older persons Commodities and equipment such as thermometer, glucometer and blood pressure machines for geriatric care were generally available across the surveyed facilities, although some services relevant to older adults such as cholesterol testing and hearing and urinary incontinence screenings were more limited (Fig. 2 and Additional file 3). Figure 2. Key provisions and gaps in health services for healthy ageing Facility design, user friendly health centre, and physical environment The physical environment in most of the facilities visited included infrastructure for AFHS. For example, 83% facilities had wide entrance, 75% had spacious corridors for wheelchair users and less than a half (46%) had toilets accessible for wheelchair users. Few facilities (25%) had ramps with grab bars, 13% had grab bars in the toilet, and only 4% had braille signages (Fig. 3 and Additional file 3). Figure 3. Facility features supporting healthy ageing care for older adults Facility health management information system One-third of the facilities reported data on healthcare services for older adults through the District Health Information System (DHIS2). Two-thirds maintained outpatient and laboratory registers including age-disaggregated data, specifically highlighting patient categories aged 40 years and above (Additional file 3). Characteristics of the age-friendly Knowledge, Attitudes, and Practices survey participants We surveyed 180 healthcare providers. Their mean age was 39 years old, and two-thirds were females. The most common job role was nurse (57.2%) and most of the workers (82.2%) had received post-secondary education. While 59.4% had experience in caring for older people, three-quarters of the surveyed providers cared for an older family member and only 10.6% of the total participants received formal training on the care of older people in the last 2 years (Table 1 ). Table 1 Characteristics of the age-friendly Knowledge, Attitudes, and Practices survey participants Variables Group N (%) Age groups of respondents 20–39 98 (54.4) 40–59 82 (45.6) Sex Female 122 (67.8) Male 58 (32.2) Level of education No formal education 1 (0.6) Post secondary 148 (82.2) Secondary 31 (17.2) Job Role Community health worker 1 (0.6) Nurse 103 (57.2) Midwife 18 (10.0) Medical doctors and laboratory technicians 58 (32.2) Duration in current role in years 20 20 (11.1) Any experience caring for older people aged 40 years and above as a healthcare provider No 73 (40.6) Yes 107 (59.4) Personal experience caring for an older family member over the age of 40 years No 50 (27.8) Yes 130 (72.2) Average Number of older persons provided care for per week 20 113 (62.8) Formal training on the care of older people in the last 2 years. No 161 (89.4) Yes 19 (10.6) Healthcare workers’ knowledge of ageing and age-friendly healthcare services The participants had a median score on the KAP survey of 58 out of 100 (Interquartile range [IQR]: 42–67) (Table 2 ). While two-thirds of the participants had heard of healthy ageing, only about one-third were familiar with the concept of AFHS for older adults. Most of the providers (88%) knew that ageing is not a disease, 72% knew that not all older people become senile, and nearly all (92.8%) recognized that physical strength declines with age. The majority (75%) of the providers rejected the stereotype that older people are unproductive and a burden to the family and society. The participants had high awareness of key factors affecting healthy ageing, such as food, lifestyle and physical diseases. However, some had limited understanding of common age-related conditions. Table 2 Knowledge of ageing and age-friendly healthcare services among healthcare providers Knowledge question N (%) Ever heard about healthy ageing (correct response “yes”) 121 (67.2) Have you ever heard about age friendly services for older adults (correct response (“yes”) 59(32.8) Ageing is a disease (correct response “no”) 158 (87.8) All old people become senile (correct response “no”) 129 (71.7) Most older people (> 40 years) carry out their own activities (correct response “yes”) 87 (48.3) All older people become weak, frail, ill or disabled (correct response” no”) 120 (66.7) All older people are alike (correct response “no”) 167 (92.8) Older people are concerned about relationships with family and friends (correct response “yes”) 124 (68.9) Physical strength declines in old age (correct response “yes”) 167 (92.8) Older people are unproductive and a burden to their family and society (correct response “no”) 135 (75) Factors affecting healthy ageing (correct responses) Heredity 155 (86.1) Activity/Lifestyle 170 (94.4) Food 176 (97.8) Physical diseases 157 (87.2) Environment 157 (87.2) Social support 157 (87.2) Four main categories of impairment in older people (correct responses) Hearing loss 78 (43.3) Memory loss 128 (71.1) Urine incontinence 131 (72.8) Depression 115 (63.9) Age friendly facility is the one that promotes Dignity 75(41.7) Health 153 (85) Harmony 59(32.8) Participation 61(33.9) Development 73(40.6) Free healthcare 89(49.4) Components of age-friendly services for older adults Preventive screening services 99(55) Behavioral counseling 97(53.9) Clinical counseling 95(52.8) User-friendly physical environment 47(26.1) Age-disaggregated data 25(13.9) Attitudes of age-friendly healthcare services Healthcare providers showed positive attitudes toward caring for older adults, with a median attitudes score of 65 (IQR: 47–82)(Table 3 ). A majority (76.7%) strongly supported establishing strong connections between health facilities and community organizations to improve care for older adults. Similarly, over 70% of providers acknowledged the importance of care models tailored for older people and emphasized the need for specialized training, knowledge, and compassionate staff in elderly care Table 3 Attitudes towards age-friendly healthcare services among 180 healthcare providers surveyed in Rwanda Attitude towards AFHS Strongly agree n (%) Agree n (%) Disagree/ strongly disagree n (%) Health facility should give priority to providing services to older persons at all points of services 122 (67.8) 54 (30.0) 4 (2.2) If needed by an individual, the facility should provide home health services to older persons 105 (58.3) 64 (35.6) 11 (6.1) It is important that the models of care of the facility support the specific needs of older persons 130(72.2) 50(27.8) 0(0) Providing care to older persons requires specific training in skills and knowledge for staff 126 (70.0) 45 (25.0) 9 ( 5 ) Providing care to older persons requires compassionate staff 125 (69.4) 40 (22.2) 15 (8.3) Primary healthcare facilities should have strategic commitment to care of the older person 123 (68.3) 52 (28.9) 5 (2.8) Primary healthcare facilities should have clinical providers who advocate for older people within the facility 130 (72.2) 45 (25.0) 5 (2.8) There should be robust links with relevant community organizations to facilitate care of older persons between the facility and community 138(76.7) 42(23.3) 0(0) AFHS: age-friendly healthcare services Practices of age-friendly healthcare services Healthcare providers reported a range of practices important to AFHS (median practices score of 59 out of 100 [IQR: 47–74]). Areas that were most often reported as never provided included access to information including clinical evidence to provide care of older patients (62.8%), provision of integrated assessment (16.7%), and planning for care and follow up on advanced care plans (11.7%). In contrast, areas that were most reported as always provided included allowing older people to provide feedback on their care (45.6%), consideration of non-hospital options for older patients’ care plans (54.4%), and support for older people in decision making and care planning (51.7%). Only 12.2% of the providers received training specific to the needs of older adults. Fewer than half reported having consistent processes and resources in place to always and sometimes identify common conditions affecting older individuals such as hearing loss and urinary incontinence, however resources to identify those conditions were limited (Additional file 4). KAP scores of age-friendly healthcare services and association with participants’ characteristics Participants with post-secondary education demonstrated higher attitude scores, while community health workers excelled in practice-related aspects of AFHS. Additionally, providers who had personal experience caring for an older family member aged ≥ 40 years exhibited the strongest knowledge of AFHS and demonstrated significantly more positive attitudes towards AFHS (β = 9.35, CI: 2.09–16.60, p = 0.012). Healthcare providers who received training on the care of older adults within the past two years showed reduced practice scores related to AFHS (β = -19.44, CI: -29.11, -9.77, p < 0.05). There was no association between KAP scores and providers’ education level, average number of older persons cared for per week and professional experience (Additional files 5a,5b). Discussion This study aimed to fill a significant gap in the knowledge around health facility and providers’ readiness to ensure effective and age-friendly care in Rwanda. This study found significant gaps in Rwanda’s primary healthcare facilities and in providers’ readiness to care for older adults. The largest gaps in this study were identified in infrastructure, human resources, service provision modalities, and care availability. In addition, there was a lack of training among healthcare workers and some areas of knowledge. These gaps were found despite the commitment of the Government of Rwanda and healthcare professionals to delivering quality AFHS, representing areas where additional capacity building is needed. Our findings agree with other studies conducted in other African settings suggesting that PHFs are not yet ready to provide effective AFHS, despite the ageing of their populations( 4 , 8 ). Only one facility had a specialized consultation section for older adults, similar to findings in Iran where only one facility surveyed had such a section and which only operated two days a week( 22 ). Similar gaps were identified in Lagos, Nigeria but these were lower than in India, where only 4% of the facilities had a multispecialty clinic for senior patients and emphasized that having a separate queue, admission and billing counters for older adults is an essential aspect of an age -friendly facility( 11 , 22 ). The present study found that 67% and 58% of the surveyed facilities prioritized older adults in labs and pharmacies, respectively, similar to rates reported in Nigeria where 86.7% and 80% of the facilities prioritized older adults at the laboratories and pharmacies( 4 ). This approach potentially reflects cultural respect for elders, but similar to what was reported in Iran was not supported by formal policies or guidelines( 22 ). None of the facilities surveyed offered home health services, highlighting a significant gap in the continuity of needed healthcare, particularly for older adults. This lack of availability of home care was also reported in Iran and Nigeria, where 4% and 20% of the surveyed facilities provided home services if needed( 4 , 22 ). Few facilities (8%)had a health worker designated to specifically help elderly people, lower than the findings reported in Nigeria and Uganda( 4 , 8 ).This finding is inconsistent with WHO recommendations on integrated care for older people, which include assigning a dedicated provider to support them. This absence of health worker designated to help elderly people maybe related to the shortage in human resources at primary healthcare facilities( 4 , 22 , 25 ). The Government of Rwanda is implementing its “4X4 reform,” aimed at quadrupling the number of healthcare workers between 2024 and 2028. It will be important for policy makers and facility leaders to designate health workers who are trained to provide the care needed by older adults( 26 ). This study showed that there were no dedicated funding or reduced costs for elderly care in surveyed facilities, reflecting absence of targeted funding – similar to findings from Uganda( 8 ), other Sub-Saharan countries, and other areas where care delivery could be strengthened( 8 ) Even though there are not more studies in Sub Saharan African countries to compare, most facilities had a safe physical environment, though accessibility challenges for wheelchair users remained, impacting not just older adults but disabled people more broadly. Only 58% had entrance ramps, and just half had non-slippery inpatient floors, lower than what reported in Nigeria and Saudi Arabia( 4 , 21 ). Toilet access for people needing additional support including wheelchair users was limited, with only 13% of facilities equipped with grab bars, aligning with Nigeria but below levels in Iran and Saudi Arabia where 23% and 40% of the facilities had grab bars around the toilet, respectively( 21 , 22 ). These findings are not in line with WHO age friendly healthcare toolkit which recommends two layered grab bars to help older people walk around safely and independently ( 12 ). Signage also did not meet best practices as per the guidelines for inside and outside signage for a PHF centre( 12 ), lower than the practices reported in Iran, highlighting the need for clear, inclusive signage to support navigation and mobility( 23 ), especially for older adults who have high rates of visual impairments( 24 ). Wheelchairs and oxygen cylinders were lacking in many facilities, posing challenges for older adults; hearing assessments were also limited, though more frequent than in studies from Nigeria and Uganda( 4 , 8 ). There was a gap in the treatment of urinary incontinence, consistent with findings reported in Uganda, despite significant rates and related morbidity for this condition( 8 ). It is critical that these items and assessments are made available at the PHFs to improve adults' quality of life. The observed gaps of not fully reporting data in DHIS2 and maintaining outpatient and laboratory registers with age-disaggregated data are consistent with other findings that the sufficient adoption of information systems remain a significant challenge in Africa( 27 – 29 ). Facilities showed gaps in recording age-disaggregated data, aligning with reporting in Uganda( 8 ) and Nigeria( 4 ). These gaps highlight a need to generate information on AFHS, enabling data-driven decisions to improve health outcomes and plan age-appropriate interventions. Despite the providers’ interest in delivering AFHS to older adults, there were substantial gaps in readiness at the individual healthcare provider level. The study found a lack of formal training of providers on care for older people. This aligns with previous research reporting insufficient training among rural health workers in Uganda, with 80% of them demonstrated poor to fair knowledge of AFHS( 9 ). Our study found a smaller proportion of trained providers to that reported in Nigeria( 4 ) and higher than figures reported in Greece( 30 ). This lack of training emphasizes an assertion that African countries are lagging in training health workers in geriatric care due to the lack of higher learning institutions that offer geriatrics training and specializations( 31 ). The surveyed providers demonstrated significant knowledge gaps regarding health conditions specific for older adults, key concepts of healthy ageing, its components and categories of impairments that affect old people such as hearing loss, arthritis, and cataracts and other eye conditions. These findings are in line with studies conducted in Nigeria which reported limited provider knowledge regarding conditions that affect healthy ageing( 4 , 11 ). Healthcare workers in this study showed positive attitudes towards AFHS delivery, in line with the findings in Nigeria and China( 4 , 32 ); however, this contrasts the findings of Tanyi and Bhatta who reported nurses’ poor and impolite behaviors towards older adults( 11 , 33 ). The low practice of screening common conditions in older adults concur with results reported in Nigeria; that study emphasized that the country’s health system must be better prepared to address the growing demands of the future elderly population, particularly in screening and managing common age-related conditions( 11 ). Training on geriatric care in the last two years demonstrated a significant inverse association with AFHS practices, suggesting that training alone may be insufficient in the absence of adequate resources to support the effective implementation of age-friendly care( 13 ). By contrast, prior experience caring for an older family member significantly improved providers’ attitude, potentially underscoring the value of personal experience in shaping healthcare providers’ attitudes related to AFHS. This finding is at odds with that of Ogunyemi and colleagues, who reported no significant association between caregiving experience for older family members and attitudes toward AFHS( 4 ). There was no association between KAP scores and providers’ education level, these findings are not aligned with what was reported in Nigeria that better educated providers showed better AFHS practices( 4 ). Surprisingly, professional experience and the number of older persons cared for per week at the facility were not associated with better delivery of AFHS. Limitations and strengths of the study This study has several strengths and limitations to consider while interpreting its results. This study provides the first published insight on the readiness of PHFs to offer geriatric friendly care services in Rwanda and used the WHO Age-Friendly Toolkit and validated tools used in similar African contexts to standardize the assessment. However, the reliance on self-reported KAP may introduce response bias. Additionally, the study focused solely on public health centers, excluding private facilities, district hospitals, and their providers, which may limit the generalizability of findings. This narrower scope potentially overlooks important dimensions of geriatric care in the broader health system. Conclusion Healthcare providers demonstrated a positive attitude toward AFHS; however, efforts are still required to enhance facility preparedness as well as providers’ knowledge and practices to improve the diagnosis, prevention, and management of geriatric conditions. For Rwanda to meet the goals of the United Nations Decade of Healthy Ageing, there is a need for policy reforms, increased investment and health financing, strengthened human resources in geriatric care, development of age-friendly environments, and improvements in health management information systems for older adults—particularly at the primary healthcare level, where most adults access services. Abbreviations AFHS Age Friendly Healthcare Services IQR Interquartile range KAP Knowledge, Attitudes, and Practices NST National Strategy for Transformation NCDs Non-Communicable Diseases PHFs Primary Healthcare Facilities Declarations Ethics approval and consent to participate The study received ethics approval from the Rwanda National Ethics Committee (Reference no: RNEC262/2023), Northwestern University, USA (IRB ID: STU00220814) and University of Birmingham, UK (IRB ID: ERN-23-0421). Written informed consents were obtained from all research participants before starting to answer the survey questions and ensured the confidentiality of their personal data using unique identification codes. Participating in the study was completely optional, and the participants were free to withdraw from the study anytime and there were no consequences associated with their withdrawals. Consent for publication Not applicable. Competing interests The authors have declared that they have no competing interests. Funding The study was funded by Robert J. Havey, MD Institute for Global Health at the Northwestern University through the Northwestern Havey Institute for Global Health Global Innovation Challenge award (1001E). Author Contribution AA, JD, CG, and LHR designed the project and led the submission of the grant application. CC, MB, FU, CK, and TY are participated in study design, data collection procedures and approach to the study. All authors critically reviewed, provided feedback, and approved the paper. Acknowledgement The authors would like to acknowledge the Government of Rwanda, through the National Institute of Statistics of Rwanda, for issuing the visa letter that facilitated access to the community. Data Availability All data underpinning the findings and conclusions of this study are fully reported within the main manuscript and the supplementary appendices. References World Social Report. Leaving None Behind In An Ageing World. 2023. Chobe M, Chobe S, Dayama S, Singh A, Metri K, Basa JR, et al. Prevalence of Non-Communicable Diseases and Its Associated Factors Among Urban Elderly of Six Indian States. Cureus. 2022 Oct;10. 10.7759/cureus.30123 . Dumith SC, Feter N. Demographic shifts and health dynamics: Exploring the impact of aging rates on health outcomes in Brazilian capitals. Archives Gerontol Geriatr Plus. 2024;1(3):100044. 10.1016/j.aggp.2024.100044 . 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BMC Geriatr. 2021;21(1):147. 10.1186/s12877-021-02098-w . WHO,2025 [Internet]. [cited 2026 Mar 11]. Available from: http://(https//www.who.int/news-room/fact-sheets/detail/ageing-and-health Alhamdan AA, Alshammari SA, Al-Amoud MM, Hameed TA, Al-Muammar MN, Bindawas SM, et al. Evaluation of health care services provided for older adults in primary health care centers and its internal environment: A step towards age-friendly health centers. SMJ. 2015;36(9):1091–6. 10.15537/smj.2015.9.11789 . Ahmadi A, Seyedin H, Fadaye-Vatan R. Towards Age-Friendly Hospitals in Developing Countries: A Case Study in Iran. Health Promot Perspect. 2015;5(1):42–51. 10.15171/hpp.2015.006 . Stevens JA, Mahoney JE, Ehrenreich H. Circumstances and outcomes of falls among high-risk community-dwelling older adults. Inj Epidemiol. 2014;1(1):5. 10.1186/2197-1714-1-5 . Mishler AD, Neider MB. Improving Wayfinding for Older Users with Selective Attention Deficits. Ergon Design: Q Hum Factors Appl. 2017;25(1):11–6. 10.1177/1064804616659992 . Wong KS, Ryan DP, Liu BA. A System-Wide Analysis Using a Senior‐Friendly Hospital Framework Identifies Current Practices and Opportunities for Improvement in the Care of Hospitalized Older Adults. J Am Geriatr Soc. 2014;62(11):2163–70. 10.1111/jgs.13097 . Rwanda Ministry of Health. 4x4 Reform: Towards Quadrupling the current workforce in 4 years (4x4); Uplifting Quantity and Quality of care.2024. Gladwin J. Implementing a new health management information system in Uganda. Health Policy Plann. 2003;18(2):214–24. 10.1093/heapol/czg026 . Isabalija DSR, Mayoka KG, Mbarika VW. Factors Affecting Adoption, Implementation and Sustainability of Telemedicine Information Systems in Uganda. 2011. World Health Organization. Framework and standards for country health information systems.2008. Avgerinou C, Kotsani M, Gavana M, Andreou M, Papageorgiou DI, Roka V, et al. Perceptions, attitudes and training needs of primary healthcare professionals in identifying and managing frailty: a qualitative study. Eur Geriatr Med. 2021;12(2):321–32. 10.1007/s41999-020-00420-0 . O K, Mmm L. Towards a Geriatrics Policy Integrated to the Primary Health Cares in Africa (The Case of Senegal). J Gerontol Geriatr Res. 2016;05(01). 10.4172/2167-7182.1000274 . Liu Ye, While AE, Norman IJ, Ye W. Health professionals’ attitudes toward older people and older patients: A systematic review. J Interprof Care. 2012;26(5):397–409. 10.3109/13561820.2012.702146 . Bhatta DN, Karki S, Aryal U. Older people's perspectives on an elderly-friendly hospital environment: an exploratory study. RMHP. 2015;81. doi:10.2147/RMHP.S83008. Additional Declarations No competing interests reported. Supplementary Files Additionalfile2.KnowledgeAttitudesandPracticesScoring.docx Additionalfile1a.Facilityreadinessquestionnaire..docx Additionalfile1b.Providersknowledgeattitudesandpracticesquestionnaire.docx Additionalfile4.PracticesofAFHSamong180healthcareproviders.docx Additionalfile5a.ProvidersknowledgeAttitudesandpracticesscoresinrelationtotheircharacteristics.docx Additionalfile3.Facilityreadinessforthedeliveryofagefriendlyhealthcareservicesinprimaryhealthcarefacilities.docx Additionalfile5b.AssociationbetweenparticipantscharacteristicsandknowledgeAttitudesandpracticesscores.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9519086","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631855458,"identity":"1fcd0861-406d-437f-87b2-7dba4dca8db4","order_by":0,"name":"Callixte Cyuzuzo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYDADfgYGNhK1SDaQrMXgALFa+NvPmEn+bKuTM76Rfu3BBwabfHkHAlokzuSYSUi2sRmb3cgpN5zBkGa58QAh90jwmEkYtvEkbruRkybNw3DYwLCBGC2JbRKJm2cAtfwhWsvBNoPEDRLpx6QZgFrkCegA+iWt2LLhXIKxxJk3bJI9BmkGBoS08Lcf3njzR1mdHH97+jOJHxU2BvKEHMbAwAEzlgfIMABHECHA/gCVQYQto2AUjIJRMMIAAJtYOOytFUAfAAAAAElFTkSuQmCC","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":true,"prefix":"","firstName":"Callixte","middleName":"","lastName":"Cyuzuzo","suffix":""},{"id":631855459,"identity":"ff97dc37-9507-4b85-a5ba-439ab4d74fde","order_by":1,"name":"Alemayehu Amberbir","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Alemayehu","middleName":"","lastName":"Amberbir","suffix":""},{"id":631855460,"identity":"7db8a89d-d7c1-48c6-8141-9fb743ceeee5","order_by":2,"name":"Michael 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10:03:46","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":71124,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile5b.AssociationbetweenparticipantscharacteristicsandknowledgeAttitudesandpracticesscores.docx","url":"https://assets-eu.researchsquare.com/files/rs-9519086/v1/8ffe9196c173dbabe3ec69f1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Age friendly services provision for older adults in Rwanda’s primary healthcare system: An analysis of facility readiness and healthcare providers’ perspectives","fulltext":[{"header":"Background","content":"\u003cp\u003eThe global population of older people is expected to be more than double by 2050, with survival to older ages increasing worldwide and in the low- and middle-income countries including Rwanda(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Associated with ageing, globally has been a rise in both noncommunicable diseases (NCDs) and conditions of older age(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These changing demographics highlight the need for primary care and public health interventions to promote healthy ageing, reduce mortality and morbidity related to NCDs, and strengthen health systems through improved infrastructure, and human resources. Primary healthcare is a cornerstone for effective and quality universal health coverage among the ageing population(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn workshops done in rural and urban Rwanda with older people and other stakeholders, access to healthcare for older people was identified as a priority issue(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Currently, weak and ineffective implementation of age-friendly healthcare services (AFHS) at primary healthcare facilities (PHFs) has resulted in enormous unmet needs for older adults, with significant gaps in capacity, access, and delivery found in Uganda and Nigeria(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These gaps in readiness include insufficient trained staff, infrastructure, and equipment. In Uganda, a study that assessed the readiness of the facilities highlighted low readiness in leadership, financing, human resources and health management information systems, equipment, and other necessary commodities for geriatric care(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Other research found that there was a lack of geriatric centers and training institutions(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Similar results were found in Nigeria including inadequately prepared systems and poor facility designs in Lagos, and challenges in screening common conditions for older individuals in Lagos, Nigeria(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo address unmet needs of older adults, the WHO has released an age-friendly healthcare centres toolkit with the purpose of improving health services delivery at the facilities and train providers on the specific needs of older persons (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Targeted recommendations focused on information and communication, education and training, healthcare management systems, and physical environment. Improving these target areas is expected to reduce conditions associated with old age, older people's admission rates at facilities, and contribute to timely and quality healthcare provision(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The 2022 Rwanda Population and Housing Census found that 21% of Rwanda\u0026rsquo;s population is aged 40 years and above, and 6.5% aged 60 years and above(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These numbers represent over 2.7\u0026nbsp;million individuals who would benefit from AFHS. Given the current and future population of older adults, there is a need to conduct interventions on how to promote healthy ageing and reduce NCD-associated multimorbidity in people of advanced ages(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The Government of Rwanda, through the Ministry of Local Government in consultation with other ministries, civil societies, and the Rwandan elders\u0026rsquo; advisory forum, has established a National Older Persons\u0026rsquo; Policy with the aim of empowering, supporting, and promoting the inclusion of older persons in all aspect of Rwandan society. A key strategy includes securing an environment in which older persons are ensured with dignity, rights to health, secured lives and responsibilities(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Rwandan health system\u0026rsquo;s readiness to meet the needs for older persons is not well documented. To support this need and to address a critical gap in understanding the readiness of health facilities and providers to deliver effective, age-friendly care in Rwanda, we measured the readiness of the PHFs in urban and rural settings to deliver effective AFHS to older people in Rwanda and the knowledge, attitudes, and experience of primary care providers in providing prevention and care for this growing population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting\u003c/h2\u003e \u003cp\u003eRwanda is a low-income country located in East Africa, with a population of about 13\u0026nbsp;million. It has five provinces and has adopted a decentralized healthcare system with 30 district health offices responsible for health services provision in their respective zones(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Rwanda has five national referral hospitals, 42 district hospitals, 500 health centres providing primary healthcare, and 1700 health posts. This study was conducted in three administrative districts (Gasabo, Nyarugenge, and Kicukiro) in the City of Kigali (urban site) and Burera district (rural site) in the Northern province. The city of Kigali has 36 health centres (16 in Gasabo, six in Nyarugenge, and 14 in Kicukiro) that serve a population of more than 1.7\u0026nbsp;million; Burera district has 19 health centres serving 387,729 people(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design, participants, and sample size\u003c/h3\u003e\n\u003cp\u003eThis cross-sectional study included a total of 24 primary healthcare centres located in both rural and urban settings of Rwanda. A simple random sampling technique was employed with the sample size limited by study resources to choose 12 of the 36 centres across the three districts in the city of Kigali, and 12 of the 19 in Burera district. One leader at every selected healthcare facility completed the facility readiness survey and at least seven consented healthcare providers per facility who were providing care and present at the time of the survey answered the Knowledge, Attitudes, and Practices (KAP) survey. Eligible healthcare workers included medical doctors, nurses, midwives, laboratory technicians, and community health workers.\u003c/p\u003e\n\u003ch3\u003eSurvey tools and data collection procedures\u003c/h3\u003e\n\u003cp\u003eThe details of the methods and conduct of this study were reported elsewhere(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In brief, tools for the facility readiness and AFHS delivery KAP surveys were adapted from the WHO age-friendly toolkit and used previously in the studies conducted in other lower- and middle-income countries(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The facility survey focused on geriatric care training and service delivery, availability of clinical services and health assessment for older persons, facility design, user friendly health centre and physical environment, and facility health management information system(Additional file1a). The KAP survey instrument captured data on healthcare workers, their demographic information, and professional experiences. The KAP survey tool had 37 questions that assessed knowledge, eight for attitudes, and 30 for practices (Additional file 1b).\u003c/p\u003e \u003cp\u003eThe survey tools were translated into Kinyarwanda, back translated, and checked for correctness. The data collection tools were pilot tested at two primary healthcare centres not included in the study, one in Burera district and another in the city of Kigali. They were further revised based on feedback from participants and research assistants to make them more relevant to the Rwandan health system context. Data on facility readiness and KAP were collected from June to July 2024 using a web-based version of the REDCap software platform. Eleven trained data collectors collected data through direct observation and structured in-person survey administration. Tape measures were used to measure the width of the facility doors and the main entrance to the facilities.\u003c/p\u003e\n\u003ch3\u003eData management and analysis\u003c/h3\u003e\n\u003cp\u003eData quality checks were conducted throughout the study, and the study used descriptive statistics including frequencies or percents for categorical variables and median and interquartile range for continuous variables. For facility readiness, a descriptive analysis was performed. For healthcare providers, the primary outcomes were KAP scores. The knowledge of ageing and AFHS was measured as yes versus no and correct versus incorrect based on WHO guidelines(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). \u0026ldquo;Yes,\u0026rdquo; and correct responses were scored as 1, incorrect, and \u0026ldquo;no\u0026rdquo; responses as 0. Questions on attitudes towards age-friendly services were scored using a four-point Likert scale as strongly agree, agree, disagree and strongly disagree scored 1, 0.75, 0.5 and 0, respectively. Practice of AFHS were measured using a three-point Likert scale (always, sometimes, and never scored 1, 0.5, and 0, respectively) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) (Additional file 2). Multiple linear regression analysis was used to measure the association between participants\u0026rsquo; characteristics and KAP scores of AFHS. A confidence interval of 95% was employed and a \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. The Stata/SE 13.0 (StataCorp LP, College Station, Texas, USA) was used for all statistical analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGeriatric care training and service delivery\u003c/h2\u003e \u003cp\u003eNone of the 24 facilities had all the needed components for delivering AFHS. There were significant facility gaps in delivering home health services, training staff, health financing, and specialized personnel to help older adults. For example, only 12.5% had staff trained on the care for older adults; 8% had a designated health worker to help them and none of the facilities delivered home health services (Fig.\u0026nbsp;1 and Additional file 3).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1. Health facility provisions for older adult care\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAvailability of equipment, clinical services, and health assessment for older persons\u003c/h3\u003e\n\u003cp\u003eCommodities and equipment such as thermometer, glucometer and blood pressure machines for geriatric care were generally available across the surveyed facilities, although some services relevant to older adults such as cholesterol testing and hearing and urinary incontinence screenings were more limited (Fig.\u0026nbsp;2 and Additional file 3).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2. Key provisions and gaps in health services for healthy ageing\u003c/b\u003e \u003c/p\u003e\n\u003ch3\u003eFacility design, user friendly health centre, and physical environment\u003c/h3\u003e\n\u003cp\u003eThe physical environment in most of the facilities visited included infrastructure for AFHS. For example, 83% facilities had wide entrance, 75% had spacious corridors for wheelchair users and less than a half (46%) had toilets accessible for wheelchair users. Few facilities (25%) had ramps with grab bars, 13% had grab bars in the toilet, and only 4% had braille signages (Fig.\u0026nbsp;3 and Additional file 3).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 3. Facility features supporting healthy ageing care for older adults\u003c/b\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFacility health management information system\u003c/h2\u003e \u003cp\u003eOne-third of the facilities reported data on healthcare services for older adults through the District Health Information System (DHIS2). Two-thirds maintained outpatient and laboratory registers including age-disaggregated data, specifically highlighting patient categories aged 40 years and above (Additional file 3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the age-friendly Knowledge, Attitudes, and Practices survey participants\u003c/h2\u003e \u003cp\u003eWe surveyed 180 healthcare providers. Their mean age was 39 years old, and two-thirds were females. The most common job role was nurse (57.2%) and most of the workers (82.2%) had received post-secondary education. While 59.4% had experience in caring for older people, three-quarters of the surveyed providers cared for an older family member and only 10.6% of the total participants received formal training on the care of older people in the last 2 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the age-friendly Knowledge, Attitudes, and Practices survey participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge groups of respondents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98 (54.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82 (45.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e122 (67.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (32.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e148 (82.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (17.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eJob Role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity health worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e103 (57.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMidwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (10.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical doctors and laboratory technicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (32.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDuration in current role in years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96 (53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (35.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAny experience caring for older people aged 40 years and above as a healthcare provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73 (40.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107 (59.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePersonal experience caring for an older family member over the age of 40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50 (27.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e130 (72.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAverage Number of older persons provided care for per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55 (30.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e113 (62.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFormal training on the care of older people in the last 2 years.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e161 (89.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (10.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare workers\u0026rsquo; knowledge of ageing and age-friendly healthcare services\u003c/h2\u003e \u003cp\u003eThe participants had a median score on the KAP survey of 58 out of 100 (Interquartile range [IQR]: 42\u0026ndash;67) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). While two-thirds of the participants had heard of healthy ageing, only about one-third were familiar with the concept of AFHS for older adults. Most of the providers (88%) knew that ageing is not a disease, 72% knew that not all older people become senile, and nearly all (92.8%) recognized that physical strength declines with age. The majority (75%) of the providers rejected the stereotype that older people are unproductive and a burden to the family and society. The participants had high awareness of key factors affecting healthy ageing, such as food, lifestyle and physical diseases. However, some had limited understanding of common age-related conditions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKnowledge of ageing and age-friendly healthcare services among healthcare providers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge question\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver heard about healthy ageing (correct response \u0026ldquo;yes\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121 (67.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHave you ever heard about age friendly services for older adults (correct response (\u0026ldquo;yes\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59(32.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgeing is a disease (correct response \u0026ldquo;no\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158 (87.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll old people become senile (correct response \u0026ldquo;no\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129 (71.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost older people (\u0026gt;\u0026thinsp;40 years) carry out their own activities (correct response \u0026ldquo;yes\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (48.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll older people become weak, frail, ill or disabled (correct response\u0026rdquo; no\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll older people are alike (correct response \u0026ldquo;no\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167 (92.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOlder people are concerned about relationships with family and friends (correct response \u0026ldquo;yes\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124 (68.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical strength declines in old age (correct response \u0026ldquo;yes\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167 (92.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOlder people are unproductive and a burden to their family and society (correct response \u0026ldquo;no\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135 (75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactors affecting healthy ageing\u003c/b\u003e (correct responses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeredity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155 (86.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity/Lifestyle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170 (94.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176 (97.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 (87.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnvironment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 (87.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 (87.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFour main categories of impairment in older people\u003c/b\u003e (correct responses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHearing loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (43.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMemory loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128 (71.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrine incontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131 (72.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (63.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge friendly facility is the one that promotes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDignity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75(41.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarmony\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59(32.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61(33.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDevelopment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73(40.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFree healthcare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89(49.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComponents of age-friendly services for older adults\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreventive screening services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99(55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavioral counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97(53.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95(52.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUser-friendly physical environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47(26.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge-disaggregated data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25(13.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAttitudes of age-friendly healthcare services\u003c/h2\u003e \u003cp\u003eHealthcare providers showed positive attitudes toward caring for older adults, with a median attitudes score of 65 (IQR: 47\u0026ndash;82)(Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A majority (76.7%) strongly supported establishing strong connections between health facilities and community organizations to improve care for older adults. Similarly, over 70% of providers acknowledged the importance of care models tailored for older people and emphasized the need for specialized training, knowledge, and compassionate staff in elderly care\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAttitudes towards age-friendly healthcare services among 180 healthcare providers surveyed in Rwanda\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude towards AFHS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrongly agree\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisagree/ strongly disagree\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth facility should give priority to providing services to older persons at all points of services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e122 (67.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf needed by an individual, the facility should provide home health services to older persons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e105 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (35.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIt is important that the models of care of the facility support the specific needs of older persons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130(72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50(27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProviding care to older persons requires specific training in skills and knowledge for staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e126 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProviding care to older persons requires compassionate staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e125 (69.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary healthcare facilities should have strategic commitment to care of the older person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123 (68.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary healthcare facilities should have clinical providers who advocate for older people within the facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThere should be robust links with relevant community organizations to facilitate care of older persons between the facility and community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e138(76.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42(23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAFHS: age-friendly healthcare services\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003ePractices of age-friendly healthcare services\u003c/h2\u003e \u003cp\u003eHealthcare providers reported a range of practices important to AFHS (median practices score of 59 out of 100 [IQR: 47\u0026ndash;74]). Areas that were most often reported as \u003cem\u003enever provided\u003c/em\u003e included access to information including clinical evidence to provide care of older patients (62.8%), provision of integrated assessment (16.7%), and planning for care and follow up on advanced care plans (11.7%). In contrast, areas that were most reported as \u003cem\u003ealways provided\u003c/em\u003e included allowing older people to provide feedback on their care (45.6%), consideration of non-hospital options for older patients\u0026rsquo; care plans (54.4%), and support for older people in decision making and care planning (51.7%). Only 12.2% of the providers received training specific to the needs of older adults. Fewer than half reported having consistent processes and resources in place to always and sometimes identify common conditions affecting older individuals such as hearing loss and urinary incontinence, however resources to identify those conditions were limited (Additional file 4).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eKAP scores of age-friendly healthcare services and association with participants\u0026rsquo; characteristics\u003c/h2\u003e \u003cp\u003eParticipants with post-secondary education demonstrated higher attitude scores, while community health workers excelled in practice-related aspects of AFHS. Additionally, providers who had personal experience caring for an older family member aged\u0026thinsp;\u0026ge;\u0026thinsp;40 years exhibited the strongest knowledge of AFHS and demonstrated significantly more positive attitudes towards AFHS (β\u0026thinsp;=\u0026thinsp;9.35, CI: 2.09\u0026ndash;16.60, p\u0026thinsp;=\u0026thinsp;0.012). Healthcare providers who received training on the care of older adults within the past two years showed reduced practice scores related to AFHS (β = -19.44, CI: -29.11, -9.77, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no association between KAP scores and providers\u0026rsquo; education level, average number of older persons cared for per week and professional experience (Additional files 5a,5b).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to fill a significant gap in the knowledge around health facility and providers\u0026rsquo; readiness to ensure effective and age-friendly care in Rwanda. This study found significant gaps in Rwanda\u0026rsquo;s primary healthcare facilities and in providers\u0026rsquo; readiness to care for older adults. The largest gaps in this study were identified in infrastructure, human resources, service provision modalities, and care availability. In addition, there was a lack of training among healthcare workers and some areas of knowledge. These gaps were found despite the commitment of the Government of Rwanda and healthcare professionals to delivering quality AFHS, representing areas where additional capacity building is needed.\u003c/p\u003e \u003cp\u003eOur findings agree with other studies conducted in other African settings suggesting that PHFs are not yet ready to provide effective AFHS, despite the ageing of their populations(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Only one facility had a specialized consultation section for older adults, similar to findings in Iran where only one facility surveyed had such a section and which only operated two days a week(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Similar gaps were identified in Lagos, Nigeria but these were lower than in India, where only 4% of the facilities had a multispecialty clinic for senior patients and emphasized that having a separate queue, admission and billing counters for older adults is an essential aspect of an age -friendly facility(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The present study found that 67% and 58% of the surveyed facilities prioritized older adults in labs and pharmacies, respectively, similar to rates reported in Nigeria where 86.7% and 80% of the facilities prioritized older adults at the laboratories and pharmacies(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This approach potentially reflects cultural respect for elders, but similar to what was reported in Iran was not supported by formal policies or guidelines(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNone of the facilities surveyed offered home health services, highlighting a significant gap in the continuity of needed healthcare, particularly for older adults. This lack of availability of home care was also reported in Iran and Nigeria, where 4% and 20% of the surveyed facilities provided home services if needed(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Few facilities (8%)had a health worker designated to specifically help elderly people, lower than the findings reported in Nigeria and Uganda(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).This finding is inconsistent with WHO recommendations on integrated care for older people, which include assigning a dedicated provider to support them. This absence of health worker designated to help elderly people maybe related to the shortage in human resources at primary healthcare facilities(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The Government of Rwanda is implementing its \u0026ldquo;4X4 reform,\u0026rdquo; aimed at quadrupling the number of healthcare workers between 2024 and 2028. It will be important for policy makers and facility leaders to designate health workers who are trained to provide the care needed by older adults(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This study showed that there were no dedicated funding or reduced costs for elderly care in surveyed facilities, reflecting absence of targeted funding \u0026ndash; similar to findings from Uganda(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), other Sub-Saharan countries, and other areas where care delivery could be strengthened(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEven though there are not more studies in Sub Saharan African countries to compare, most facilities had a safe physical environment, though accessibility challenges for wheelchair users remained, impacting not just older adults but disabled people more broadly. Only 58% had entrance ramps, and just half had non-slippery inpatient floors, lower than what reported in Nigeria and Saudi Arabia(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Toilet access for people needing additional support including wheelchair users was limited, with only 13% of facilities equipped with grab bars, aligning with Nigeria but below levels in Iran and Saudi Arabia where 23% and 40% of the facilities had grab bars around the toilet, respectively(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). These findings are not in line with WHO age friendly healthcare toolkit which recommends two layered grab bars to help older people walk around safely and independently (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Signage also did not meet best practices as per the guidelines for inside and outside signage for a PHF centre(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), lower than the practices reported in Iran, highlighting the need for clear, inclusive signage to support navigation and mobility(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), especially for older adults who have high rates of visual impairments(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Wheelchairs and oxygen cylinders were lacking in many facilities, posing challenges for older adults; hearing assessments were also limited, though more frequent than in studies from Nigeria and Uganda(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). There was a gap in the treatment of urinary incontinence, consistent with findings reported in Uganda, despite significant rates and related morbidity for this condition(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). It is critical that these items and assessments are made available at the PHFs to improve adults' quality of life.\u003c/p\u003e \u003cp\u003eThe observed gaps of not fully reporting data in DHIS2 and maintaining outpatient and laboratory registers with age-disaggregated data are consistent with other findings that the sufficient adoption of information systems remain a significant challenge in Africa(\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Facilities showed gaps in recording age-disaggregated data, aligning with reporting in Uganda(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and Nigeria(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These gaps highlight a need to generate information on AFHS, enabling data-driven decisions to improve health outcomes and plan age-appropriate interventions.\u003c/p\u003e \u003cp\u003eDespite the providers\u0026rsquo; interest in delivering AFHS to older adults, there were substantial gaps in readiness at the individual healthcare provider level. The study found a lack of formal training of providers on care for older people. This aligns with previous research reporting insufficient training among rural health workers in Uganda, with 80% of them demonstrated poor to fair knowledge of AFHS(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Our study found a smaller proportion of trained providers to that reported in Nigeria(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and higher than figures reported in Greece(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). This lack of training emphasizes an assertion that African countries are lagging in training health workers in geriatric care due to the lack of higher learning institutions that offer geriatrics training and specializations(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe surveyed providers demonstrated significant knowledge gaps regarding health conditions specific for older adults, key concepts of healthy ageing, its components and categories of impairments that affect old people such as hearing loss, arthritis, and cataracts and other eye conditions. These findings are in line with studies conducted in Nigeria which reported limited provider knowledge regarding conditions that affect healthy ageing(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Healthcare workers in this study showed positive attitudes towards AFHS delivery, in line with the findings in Nigeria and China(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e); however, this contrasts the findings of Tanyi and Bhatta who reported nurses\u0026rsquo; poor and impolite behaviors towards older adults(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The low practice of screening common conditions in older adults concur with results reported in Nigeria; that study emphasized that the country\u0026rsquo;s health system must be better prepared to address the growing demands of the future elderly population, particularly in screening and managing common age-related conditions(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTraining on geriatric care in the last two years demonstrated a significant inverse association with AFHS practices, suggesting that training alone may be insufficient in the absence of adequate resources to support the effective implementation of age-friendly care(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). By contrast, prior experience caring for an older family member significantly improved providers\u0026rsquo; attitude, potentially underscoring the value of personal experience in shaping healthcare providers\u0026rsquo; attitudes related to AFHS. This finding is at odds with that of Ogunyemi and colleagues, who reported no significant association between caregiving experience for older family members and attitudes toward AFHS(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere was no association between KAP scores and providers\u0026rsquo; education level, these findings are not aligned with what was reported in Nigeria that better educated providers showed better AFHS practices(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Surprisingly, professional experience and the number of older persons cared for per week at the facility were not associated with better delivery of AFHS.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and strengths of the study\u003c/h2\u003e \u003cp\u003eThis study has several strengths and limitations to consider while interpreting its results. This study provides the first published insight on the readiness of PHFs to offer geriatric friendly care services in Rwanda and used the WHO Age-Friendly Toolkit and validated tools used in similar African contexts to standardize the assessment. However, the reliance on self-reported KAP may introduce response bias. Additionally, the study focused solely on public health centers, excluding private facilities, district hospitals, and their providers, which may limit the generalizability of findings. This narrower scope potentially overlooks important dimensions of geriatric care in the broader health system.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHealthcare providers demonstrated a positive attitude toward AFHS; however, efforts are still required to enhance facility preparedness as well as providers\u0026rsquo; knowledge and practices to improve the diagnosis, prevention, and management of geriatric conditions. For Rwanda to meet the goals of the United Nations Decade of Healthy Ageing, there is a need for policy reforms, increased investment and health financing, strengthened human resources in geriatric care, development of age-friendly environments, and improvements in health management information systems for older adults\u0026mdash;particularly at the primary healthcare level, where most adults access services.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAFHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAge Friendly Healthcare Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterquartile range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKnowledge, Attitudes, and Practices\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Strategy for Transformation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-Communicable Diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHFs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Healthcare Facilities\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study received ethics approval from the Rwanda National Ethics Committee (Reference no: RNEC262/2023), Northwestern University, USA (IRB ID: STU00220814) and University of Birmingham, UK (IRB ID: ERN-23-0421). Written informed consents were obtained from all research participants before starting to answer the survey questions and ensured the confidentiality of their personal data using unique identification codes. Participating in the study was completely optional, and the participants were free to withdraw from the study anytime and there were no consequences associated with their withdrawals.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors have declared that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe study was funded by Robert J. Havey, MD Institute for Global Health at the Northwestern University through the Northwestern Havey Institute for Global Health Global Innovation Challenge award (1001E).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAA, JD, CG, and LHR designed the project and led the submission of the grant application. CC, MB, FU, CK, and TY are participated in study design, data collection procedures and approach to the study. All authors critically reviewed, provided feedback, and approved the paper.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to acknowledge the Government of Rwanda, through the National Institute of Statistics of Rwanda, for issuing the visa letter that facilitated access to the community.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data underpinning the findings and conclusions of this study are fully reported within the main manuscript and the supplementary appendices.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Social Report. Leaving None Behind In An Ageing World. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChobe M, Chobe S, Dayama S, Singh A, Metri K, Basa JR, et al. Prevalence of Non-Communicable Diseases and Its Associated Factors Among Urban Elderly of Six Indian States. 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RMHP. 2015;81. doi:10.2147/RMHP.S83008.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Facility readiness, age-friendly healthcare services, knowledge attitudes and practices, ageing, primary care, Rwanda","lastPublishedDoi":"10.21203/rs.3.rs-9519086/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9519086/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEnsuring the effective provision of age-friendly healthcare services (AFHS) is critical for addressing the needs of older adults, yet gaps remain in the health systems in Africa. This study examined primary healthcare facilities and providers\u0026rsquo; readiness in delivering AFHS in rural and urban districts in Rwanda.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study included 24 PHFs and 180 providers in the Burera district in the northern province and in Nyarugenge, Kicukiro, and Gasabo districts across the city of Kigali, using surveys developed based on the WHO\u0026rsquo;s age-friendly toolkit. A facility readiness survey gathered information on training, service availability, health assessments, and facility design. A provider survey captured providers\u0026rsquo; demographics and knowledge, attitudes, and practices about care for older people and AFHS. Data were collected using REDCap and statistically analyzed using descriptive statistics and multiple linear regression analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study found that all facilities were inadequately prepared to provide AFHS. Only 12.5% of facilities had staff trained in geriatric care, 8% had a worker to help older adults, and 4% had a special consultation area for them. Furthermore, no facilities provided home health services or budget or cost reductions for older patients. All facilities had glucometers, thermometers, and blood pressure machines, but some facilities lacked infrastructure features such as grab bars (13%) and accessible toilets (46%). The majority of the surveyed facilities had processes to identify older adult conditions; however, resources were limited. Two-thirds of the facilities did not assess hearing ability, while more (71%) assessed vision. Only 25% had process to screen for suspected elder abuse. Over half of providers (59%) had experience caring for older adults at the facilities and 72% had experience caring for an older family member. Most of the providers (67%) had heard about healthy ageing, but only 33% were familiar with AFHS. Just 11% of providers had received formal training on older adult care, and few (12%) were trained on older people\u0026rsquo;s specific needs.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePrimary healthcare facilities and their providers in Rwanda are not yet prepared to deliver effective AFHS. Improvements are needed in infrastructure, human resources, training, health financing, and service delivery.\u003c/p\u003e","manuscriptTitle":"Age friendly services provision for older adults in Rwanda’s primary healthcare system: An analysis of facility readiness and healthcare providers’ perspectives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 10:03:40","doi":"10.21203/rs.3.rs-9519086/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cc65ebba-dd3a-4df5-a60f-070319610000","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-05T11:11:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-29T14:24:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-29T14:24:06+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T11:27:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 10:03:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9519086","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9519086","identity":"rs-9519086","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}