MGHD 2022

Background: Lack of proper menstrual hygiene management (MHM) in schools has exacerbated girls’ school absenteeism and dropout rates. Previous studies in Rwanda have shown that most students receive MHM information from teachers. However, there is a paucity of data on how knowledgeable and aware the schoolteachers (STs) and school administrators (SAs) are, regarding MHM, as the key stakeholders of MHM in schools. The World Food Programme (WFP) in collaboration with World Vision (WV) has contributed to MHM by constructing sanitary rooms for girls in schools. This study was conducted to assess the knowledge, attitudes, and practices (KAP) of menstrual hygiene management among schoolteachers and school administrators, in schools with sanitary room activity (SRA) compared to those without and explore further the perceptions and involvement of male teachers and school administrators on MHM education. Methods: This school based cross-sectional study was a concurrent mixed-method study, conducted in four rural districts of Rwanda. These were Nyamagabe and Nyaruguru from the southern province, Karongi, and Rutsiro from the western province. A survey was done among 538 schoolteachers and 58 school administrators from 45 schools to assess KAP on MHM in schools with SRA compared to those without. In addition, 8 focus group discussions (FGDs) and 8 key informant interviews (KIIs) from 8 schools were conducted to explore the perceptions and involvement of male teachers and administrators on MHM education and associated socio-cultural beliefs. Descriptive analysis, logistic regression, and chi-square tests were used to analyze quantitative data with 95% CI, P<0.05 considered as the level of significance. Inductive content analysis was used to analyze qualitative data. Results: A total of 62.9% of participants had good knowledge scores (≥80%). The mean knowledge score was 82.6% (SD: 2.08). In the bivariate analysis, knowledge score was higher among female schoolteachers/administrators compared with male schoolteachers/administrators (P<0.001). All participants disagreed that “During menstruation, girls should not help in household activities” among other activities, however participants who had poor knowledge were more likely to agree that “During menstruation, girls should be scared” (OR 3.37, 95% CI: 1.80-6.31, P<0.001). Regarding practice, participants who agreed that they support MHM, 46.6% rarely helped students. Both school categories had good knowledge regardless of the presence or absence of a sanitary room. Qualitative findings revealed willingness of male schoolteachers and administrators towards MHM support, however hindered by some socio-cultural norms around menstruation. Conclusion: The good knowledge of schoolteachers and administrators on MHM, demonstrated significant efforts Rwanda has put in MHM for girls compared to other countries. However, there are still some knowledge gaps. Socio-cultural norms have also impeded the transformation of good knowledge into positive attitudes and good practices of MHM, hence increasing menstrual stigma among girls. Alongside advancing MHM training in schools, there’s need to uproot socio-cultural norms/taboos at school and community level through use of multi-media approaches in encouraging open discussions and positive norms on menstruation. This can be accompanied with sensitization of male involvement in MHM since the study highly showed female teachers were more involved in MHM than male teachers.

Background Evaluating out-of-pocket (OOP) expenses is important to understand the financial burden incurred by patients undergoing breast cancer diagnostic evaluation in order to inform early detection programs. This study aimed at adapting and testing a tool to measure out-of-pocket (OOP) costs to individuals undergoing evaluation of breast concerns through the Breast Cancer Early Detection (BCED) program at the Butaro Cancer Center of Excellence (BCCOE). The tool adapted in this study, the Cost for Patients Questionnaire (CoPaQ), was originally developed and validated by Maude Laberge in 2021 to measure health-related OOP costs to patients (Laberge et al., 2021). Minor modifications and restructuring were made to the CoPaQ to fit the breast cancer and Rwandan settings. This study was completed in July 2022. Methods We adapted and tested a tool at the BCCOE to measure OOP costs to individuals undergoing evaluation of breast concerns through the BCED program. The CoPaQ, from which our tool was adapted, is made up of 32 questions. Upon review, items on the patient health insurance status were added and the tool was translated to Kinyarwanda language. The resulting adapted tool of 33 items was subjected to face and content validity test. A consensus in a selected panel of 13 experts was calculated to assess the relevance of the items in the adapted tool using the Delphi method. Of the 33 items, 33 were retained, and an additional 9 items were added by the experts. The resulting 42 items were subjected to a four-guideline cognitive test using a Likert-like scale in 4 breast cancer patients that were randomly selected. Results The data collected from the feedback of experts showed high validity of the adapted tool. Consensus in a Delphi method was calculated with a cut-off of 50% of experts’ agreement. However, 2 items that scored 46% in the consensus were retained after considering the specific settings that are unique to BCCOE. The items in the adapted tool were all retained, and the tool had 42 items at the end of the Delphi method. The cognitive testing showed that the participants highly agreed on the score of each guideline (SD<0.3). This means that the participants found the adapted tool to be comprehensible, easy to answer, with easily navigable response options, and well-structured

Background: Discrimination, Harassment, and Violence (DHV) is perpetrated against individuals in Kenya based on real or perceived sexual orientation or gender identity (SOGI) at rates estimated to be higher than the general Kenyan population (Müller et al., 2021). Recent peer-reviewed survey studies show high lifetime prevalence of violence towards Kenyan LGBTIQ+ study participants ranging from 42% to 61.3%, but there lacks documentation of specific DHV cases, except for one study focusing on Key Populations (Bhattacharjee et al., 2018; Harper et al., 2021; Müller et al., 2021). Methods: This study analyzed secondary data utilizing records of 953 cases of DHV against LGBTQ+ (Lesbian, Gay, Bisexual, Trans, Queer, and other gender and sexual minority) individuals across three geographic clusters in Kenya documented by the galck+ Emergency Security Response (ESR) mechanism from January through December 2021. Differences in case type, police reporting, case progress, perpetrators of cases, assistance type and challenges were evaluated across geographical clusters and/or survivor SOGI. Results: Over half (54.70%, n=521) of the cases reported were harassment (40.6%, n=387) and physical violence (14.1%, n=134). These were followed by cases of blackmail (7.8%, n=74), threats of violence (5.6%, n=53), and intimate partner violence (IPV; 4.2%, n=40). Only 17.9% (n=171) of the cases reported in 2021 were successfully reported to police. Psychosocial support (n=418, 40.5%) was the most reported type of assistance provided by the galck+ ESR mechanism in 2021. Batian cluster reported significantly higher rates of police reporting, while Lenana cluster recorded significantly higher rates of cases perpetrated by police. Compared to survivors of other sexual orientations bisexual survivors reported cases to the police at higher rates and lesbian survivors reported cases of violence at higher rates. Conclusion: The implications of this work are both immediate and long-term. Firstly, this quantitative analysis of the galck+ ESR mechanism will be immediately utilized by galck+ and their member organizations for both improvement of their security response practices and as evidence for resource mobilization. The results of this study add to the existing body of literature utilizing both quantitative and qualitative methods to evaluate DHV perpetrated against LGBTQ+ populations in Africa. However, future studies are needed to quantify population-level experiences of DHV among the LGBTQ+ population and qualitative work is needed to identify the unique contextual factors that drive these events in the Kenyan context.

The study evaluated the socio-economic impact of the Partners In Health (PIH) /Inshuti Mu Buzima (IMB)- supported cooperative on the members living in the Butaro sector in Rwanda. A pre-and post-intervention study was conducted to assess the change in member’s income, the total amount of savings, the number of livestock owned (cows, sheep, goats), the ability to afford food, the ability to pay healthcare insurance for self and family, the ability to pay school fees for children, the ability to pay rent, house, and land ownership. A questionnaire was administered to a total of 150 participants. The study indicated a significant improvement in monthly income and the total amount of saving after joining the cooperative. The change in income of the cooperative members translated to a significant improvement in members’ ability to afford food, pay insurance for themselves and their families, the ability to pay school fees for children, and house and sheep ownership after joining the PIH/IMB-supported cooperative. The study found that by improving members' income and savings, the cooperative successfully raised the socioeconomic standing of its members. However, a proportion of members’ economic status remained unchanged and a small percentage reported deterioration. Further studies to investigate this is needed. Moreover, studies to include nonmembers as a comparison group can fully evaluate the socio-economic effects of the PIH/IMB-supported cooperative.

Background Many non-governmental organizations are working in sub-Saharan Africa to improve healthcare services in the region. However, in many cases, the impact of these organizations’ interventions remains unknown. This study was, therefore, carried out to evaluate the impact of Bulamu Healthcare, an organization working in partnership with the Ministry of Health in Sheema district of Uganda. Bulamu Healthcare is a non-profit organization working to strength health systems in Uganda through provision of management information system that provides timely actionable data. Methods The study was a quasi-experimental quantitative design which utilized secondary data collected by Bulamu Healthcare from 17 health facilities in Sheema district, Uganda, during the pre-and post-HCE interventions patients’ satisfaction surveys which included 556 respondents. The University of Global Health Equity’s Institution Review Board approved to carry out the study. Results The study found that patients’ satisfaction with health services in Sheema district significantly increased in the post-HCE period in all areas assessed during the study periods. The median (IQR) overall patient satisfaction increased from 39.57% (31.82% – 47.37%) in 2018 to 100% (95.83% – 100%) in 2021 with p<0.001. The demographic characteristics of respondents were not associated with patient satisfaction in both pre- and post-HCE periods. Conclusion The results of this study suggested that Bulamu Healthcare’s HCE program positively impacted patients’ satisfaction with public healthcare services in Sheema district. However, another comparative study between Bulamu-supported and non-supported facilities would be better to validate if the increase in patient satisfaction is due to Bulamu interventions or the healthcare delivery in Uganda improved.

Background: Contraceptive use among youth below 19 years in Rwanda is still very low, as low as 3.7%, yet their level of sexual activity is high. By 2020, 42% and 31% of women and men respectively had initiated sex before the age of 20 years. Rwanda’s total population is composed of 67% young people below 25 years. Low contraceptive use among this youth population increases their risk of unintended pregnancies, sexual violence, and sexually transmitted infections. Additionally, 61.3% of Rwanda’s population lives in informal settlements/slums. It has been documented, for example, that those residents of urban slums in Kenya engage in riskier sexual practices, with reduced access to sexual and reproductive health services, and have a higher HIV prevalence than urban non-slum residents (J. Madise et al., 2012). There is no study in Rwanda that has examined contraceptive use among youth living in impoverished communities, herein our study described as informal urban settlements/slums. Aim: To identify and quantify the barriers to contraceptive access and use among youth, aged 15-24 years, living in informal urban settlements in Kigali. Methodology: This is a quantitative cross-sectional study based on a convenience sample of 323 participants from youth centers and institutions of learning who completed a structured questionnaire. Results: A total of 323 respondents participated in this study. Most of them were – aged 15- 19 years old (n=194, 60.1%); females (n=184, 57%); single (n=304, 94.1%); had attained or were currently in secondary school (n=265, 82%); students (n=232, 71.8%) by occupation, and Christians (n=288, 89.2%) by religion. The respondents demonstrated high awareness of contraception 317 (98.1%) with the most frequent source of information being schools (72.4%). However, their awareness was mostly limited to male condoms 302 (93.5%), so was their use (75.2%). Most respondents (70.6%) reported the source of their contraceptives to be boutiques or pharmacies. About 40.6% of the respondents had already had sex with the average age of sexual initiation being 17.43 years. Perceived or real lack of confidentiality and privacy from the service points and providers, unavailability of contraceptives in schools, restrictive laws, fear, and concerns/myths about contraceptives and feeling embarrassed or ashamed to obtain contraceptives were highly reported to have been barriers to access and use of contraceptives among respondents. But statistically “pressure to birth” was the only significant barrier which had a predictive relation with using contraceptive utilization with OR=4.286, CI [1.219, 15.068] and was associated with marital status of the respondents. Those who were married were four times not likely to use contraceptives. Discussion: The level of contraceptive education and services that youth are getting in Rwanda is applaudable, but a lot still needs to be done to diversify the awareness of other forms of contraception other than male condoms. The government collaborative initiative with local NGOs to place kiosks/boutiques in informal settlements has improved access to contraceptives among the youth. However, constant stocking of different forms of contraceptives which is currently lacking is necessary for these boutiques/kiosks to serve a better purpose of their existence. There is need to do a qualitative study to understand further the contextual barriers faced by youth living in informal urban settlements of Kigali.

Overview One of the most significant public health issues affecting a substantial number of individuals worldwide is gender-based violence (GBV). To better assist GBV survivors, Rwanda began the Isange One-Stop Center (IOSC) program to provide comprehensive services to survivors inclusive of mental health support. Studies exploring experiences and challenges of service providers in mental health service provision and the intersectionality of services are scarce. Objective The study's goal was to understand the challenges of service providers in the practice of mental service provision at urban and rural one-stop centers. The study aimed to identify gaps and areas of improvement for enhancing the delivery of psychosocial services at IOSC. In addition, the study tries to give insights through the lens of the intersectionality framework. Methods The study is a qualitative phenomenological study, where 18 in-depth interviews were carried out using a semi-structured interview guide in June 2022. Participants included a multi-sectoral set of service providers involved in providing psychosocial support to GBV survivors at IOSCs in urban and rural settings. The data was analyzed through Dedoose software. Results Five major themes emerged. These include the psychological impact of working at the IOSCs on service providers, barriers to accessing mental health services, service providers' perspectives on the role of intersectionality in mental health service provision, and a comparison of the services offered to GBV survivors in the two studies settings. In addition, there is a theme on service providers' suggestions for improving IOSC services. Each theme is broken down into sub-themes that explain the findings in greater depth. The study revealed that working at the IOSCs had a significant psychosocial impact on the service providers with little support available at the centers. It also showed that the shortage of financial resources at IOSCs and obstacles faced by survivors such as culture, stigma, lack of transport, and information influenced access to services. When comparing results based on the setting, the lack of mental health experts and full-time staff in rural IOSC impacted the level of mental health services provided. Furthermore, it was evident that providers need more regular training in various aspects of service delivery, including mental health provision. The understanding of different social groups by providers seemed to be lacking. Service providers also recommended capacity building to enhance their knowledge of intersectionality to tailor services based on the needs of survivors. On the other hand, this study demonstrates the strength of the Isange one-stop centers in its efforts to utilize available resources to deliver comprehensive services to GBV survivors. Conclusion According to the study's findings, the level of psychosocial support provided to GBV survivors varied across rural and urban centers. Therefore, more attention needs to be given to reviewing the operations of IOSC facilities in different settings and addressing the gaps identified. Additionally, identifying the effects that providing this service has on the service providers' mental health and responding to this impact must be made a priority.

Background: Access to contraceptives by adolescents has become a global health concern. According to WHO, 12 million adolescents aged 15-19 years give birth each year, mainly in low and middle income countries with at least 10 million of these pregnancies unintended. Despite FP2020’s commitment to provide 120 million women and girls an opportunity to use life-changing modern contraceptives by the end of 2020, 23 million adolescents still have an unmet need for contraceptives. In Mahama refugee camp, there has been observed an increase in teenage pregnancy despite the presence of various campaigns aimed at reducing these pregnancies. There are no studies that explored the lived experiences of adolescent refugee girls in Mahama camp, highlighting barriers and enabling factors influencing their accessibility to contraceptive services. Such a study is vital for informing interventions aimed at reducing teenage pregnancies in the camp. This study adopts the social cognitive theory, highlighting the environment, behavioral, and cognitive determinants influencing adolescent access to contraceptive services. This study aimed at exploring community-level factors influencing the accessibility of contraceptive services among adolescent girls aged (10-19 years) in Mahama camp and proffer recommendations by August 2022. Methods: This was a qualitative study to explore lived experiences of adolescent refugee girls, and sexual and reproductive health service providers to inform interventions to curb teenage pregnancy and promote the sexual and reproductive health of adolescent girls in the camp. With informed consent from parents or guardians and ascents adolescents under age 18, 25 in-depth interviews were conducted with adolescent girls and service providers using a semi-structured interview guide. Interviews were conducted and recorded in Kinyarwanda, and further transcribed and translated into English. The transcripts were read in detail followed by the development of a codebook. The coding of transcripts was done using Dedoose software version 9.0.54 and emerging themes were identified and categorized. Results: The results showed that the enablers for contraceptive use among adolescent refugee girls were majorly environmental determinants and these were influenced by cost of service, sufficient support from service providers, frequent community awareness campaigns, location and setting of service centers, as well as knowledge on contraception. The main barriers to accessibility of contraceptive use by adolescent refugee girls were based on environmental and behavioral determinants. These barriers were influenced by cultural and religious norms, fear, and misconceptions about contraception. Out-of-stock of contraception, paucity of funds to provide services, and as well as the shortage of service providers also contributed to the barriers faced by adolescents in accessing contraceptives. The study recommended intensifying awareness on the availability of contraceptives in the camp, having sufficient health care workers to provide SRH services and more youth centers that would offer services to adolescents. Conclusion: The findings suggest the need for a joint effort by all stakeholders to ensure that contraceptives are constantly available at the service points while amplifying community awareness programmes where the community is educated on the need for contraceptive use among adolescent refugee girls. Increasing the number of health care workers would also improve access to contraceptives to these girls. The study findings also recommend that there should be revision and amendment of laws that pose age-based restriction for adolescents to access contraceptives.

Introduction Adolescents experience exacerbated vulnerability in refugee settings, where there is often an increase in sexual violence and a deficient emphasis on their right to access SRH services. Mugombwa refugee camp in Rwanda is home to 11,304 refugees from the DRC, of which 18.4% are between the ages of 12-17. In 2021, there were 47 adolescent childbirths, and in 2022, five positive cases of HIV between the ages of 12-17. This study aimed to understand the knowledge, perceptions, and utilization of SRH services among female and male adolescents following the health belief model via a feminist intersectional approach. This study also centers on the voices of adolescents to explore their barriers and recommendations. Methods This study employed a convergent parallel mixed-methods study design. Simple random and purposive sampling methods were used to select 422 quantitative and 32 FGD participants, respectively. A semi-structured questionnaire was used to collect quantitative data on knowledge, perceptions, and utilization of SRH services, while FGD guide collected information on barriers and recommendations. Descriptive statistical analysis, bivariate analysis, and multinomial logistic regression were performed on quantitative data. Qualitative data were transcribed, translated, and analyzed using deductive thematic content analysis. Results Under half of all adolescents had low SRH knowledge, and males had higher SRH knowledge than females. Predictive factors of high SRH knowledge among males were being 15-19 years old, ever having sex, and not being disabled, and among females, being 15-19 and having a child. The vast majority of adolescents had high knowledge of SRH services in Mugombwa camp. Predictive factor of high service knowledge among females was a high level of SRH knowledge. Most adolescents had positive perceptions toward contraceptive services; however, some felt service providers were judgmental. Of the participants who had ever had sex, 38.3% had never utilized contraceptives, mainly due to fear of side effects. Predictive factors of contraceptive utilization among males were high SRH knowledge and being out of school. More males had ever been tested for STIs than females, and while 91.0% of adolescents reported the desire to know their HIV status, only 48.1% had ever tested. Common predictive factors of testing for HIV and STIs were being out of school, being 15-19 years old, and having high SRH knowledge. The five major themes surrounding barriers and recommendations were: 1) socio-cultural factors; 2) the need for improved SRH service delivery; 3) parents as SRH stakeholders; 4) lack of knowledge preventing contraceptive utilization; and 5) negative perceptions preventing STI and HIV utilization. Conclusion Many adolescents have low SRH knowledge, positive perceptions of SRH services, and yet sub-optimal utilization of contraceptive, STI, and HIV services. The intersectional identities and socio-cultural factors associated with being an adolescent refugee impact the knowledge, perceptions, and utilization of contraceptive, STI, and HIV services and must be further prioritized to curb teenage pregnancy, STIs, and HIV among adolescent refugees. Increasing the regularity of SRH training and human resource capacity and training youth and parents as champions of SRH in Mugombwa Refugee camp are recommended.

Background: Good quality data enables proper decision making in healthcare settings leading to better planning, higher management efficiency and improved patient outcomes. This study aimed to assess the quality of the Yendanafe data system in Malawi. The Yendanafe data system was designed to promote comprehensive patient care and improve public health services through an evidence-based approach. The study highlights the strengths of the system and its potential limitations while proposing opportunities for improvement. Methods: An explanatory mixed approach was used to evaluate the Yendanafe data system using three distinct sources: 1) data quality dimensions, 2) survey data, and 3) focus group discussions and interviews. An analysis was conducted using all available retrospective data collected in the Yendanafe data system between January 1 and December 31, 2021. Twelve data sets were extracted for quality data dimension analysis for examination of 96 variables and 254,736 observations in total. Data completeness, timeliness, accuracy, and consistency were reviewed and benchmarked against existing standards. A quantitative survey using a Likert scale approach was conducted on a random proportional sample of community health workers (n=131) at the participating sites to identify end-user perspectives and potential sources of variability. Focus group discussions and interviews were conducted to review the preliminary findings of the quality data dimensions and survey analyses, to evaluate possible root causes of the observed limitations, and identify possible solutions. Two focus group discussions were held with a randomly selected group of community health workers (n=19) as end-users of the Yendanafe data system. In addition, in-depth interviews with six PIH staff members well versed in the use of Yendanafe were conducted. Results Our results indicate that the Yendanafe system data is complete and reported in a timely manner (completeness=89.70%, timeliness=87.40%). While accuracy of the data remainsinconclusive due to lack of a gold standard for reference. Data has also been shown to be highly consistent within the system (98.77%). Overall, data quality dimensions met or even exceeded the World Health Organization standards for all quality data dimensions except accuracy. Data gathered through community health worker surveys, focus group discussions and interviews confirmed the ease-of use and practicality of the system and identified possible areas of improvement including: technology (devices, chargers), connectivity (remote synchronization, air-time), methods (design of case report forms), processes (standardized guidance), and training (length and content). Our study recommends subsequent study to validate the accuracy of the Yendanafe System and another study to assess the accuracy of EMR data system. This study further recommends sufficient trainings and education for CHWs, more technical support and systems design and improvement. Conclusion: The Yendanafe system is an innovative and powerful tool that has the potential to revolutionize data collection and use to contribute positively to the improvement of the health care system in Malawi

Background: Menstrual hygiene management (MHM) is integral to a woman’s health and requires access to clean sanitary products, resources to wash her body, and safe places to dispose of used menstrual products. Objective: Describe the perceptions, practices, financial burden, and environmental factors that influence the experiences of menstruation for public, government aided, and private lower secondary school girls in Rwanda in 2022. Methods: In this cross-sectional study, a quantitative survey was conducted at one randomly selected public, government aided, and private school in each of Rwanda’s five provinces. The survey was administered in-person to menstruating girls in lower secondary school years 2 and 3 from March to June in 2022. The research team conducted a checklist surveying the water, sanitation, and hygiene (WASH) facilities and resources at each school. The quantitative survey described the participants' practices and preferences surrounding menstrual hygiene management and assessed the financial burden of menstruation. Students reported most frequently used MHM products during menstruation, source of information about MHM, and access to MHM WASH facilities and products. The annual cost of menstruation was calculated as a composite of the cost of MHM products and transportation required to access products. Quantitative measures were disaggregated by school type and reported descriptively with frequencies and counts. Quantitative analysis to test for the association between variables was conducted. WASH checklist data was reported with frequencies and counts. Results: A total of 1,117 menstruating girls were surveyed at fifteen schools in Rwanda. Most girls used disposable sanitary pads while menstruating (89.3%). Lack of money was the primary barrier for not accessing the MHM supplies they needed (61.3%). Out of 645 respondents, 81.7% of girls missed four or fewer days of school per year due to menstruation. Girls also missed spiritual activities (43.2%), sporting activities (36.3%), and social activities (20.3%) due to menstruation. MHM cost girls a median of 4,000 RWF per menstrual cycle. There was a statistically significant difference in cost among school types, with girls from private schools spending the least on MHM. During site visits, researchers found that almost half of schools (n=7) had no water source on campus and most schools had pit latrines (n=13). Girls primarily disposed of used sanitary products in pit latrines at home and school (>78%). Ten schools had menstrual hygiene rooms on site. Conclusion: Most surveyed girls who are enrolled in lower secondary school years 2 and 3 in Rwanda menstruate, though they do not always have sufficient resources to manage their menstruation safely and privately. MHM education, access to sanitary products, and WASH facilities is integral to a girls’ engagement in school and social activities.

Introduction Men who have sex with men (MSM) and transgender women (TGW) around the globe and in Rwanda are at higher risk than the general population of being subject to sexual health disparities, as well as disparities pertaining to the affordability and accessibility of sexual and reproductive health care services (UNAIDS, 2019). As a result of discrimination and marginalization, the vulnerability of socially disadvantaged groups such as MSM and TGW is reinforced; especially, as it relates to sexual and reproductive health (SRH) care. Accordingly, this study was conducted to explore the perspectives of MSM & TGW populations, highlight the barriers they experience accessing the SRH services and give rise to community-informed recommendations for improvements across the SRH care provision spectrum in Rwanda. Methods An exploratory sequential mixed-methods study was conducted. Four semi-structured focus group discussions (FGDs) were conducted with members of the MSM and TGW populations in Rwanda. Subsequently, a quantitative survey was administered to 134 members of the identified population to ascertain the magnitude of the barriers and assign weight to the recommendations that were highlighted in the FGDs. Results Four main themes emerged from the focus group discussions. The qualitative results highlighted the notable disparities experienced in SRH service/care in rural versus urban settings, the preference for/recommendation of specialized services for these populations and the enabling impact that NGOs like Hope and Care can have on the acquisition of equitable, accessible SRH care. Lastly, the focus groups highlighted that despite the harassment and stigma this community faces at the hands of healthcare providers and society in general, they are highly empowered in their own sexual and gender identities and serve as active agents in their own SHR care seeking. The quantitative portion of the study corroborated the results of the focus group discussions, confirming the challenges faced by these populations while accessing SRH care due to harassment by healthcare providers, societal stigma, fear of outing and disclosure of identity, violence, stockouts and lack of knowledge of healthcare providers regarding issues that affect their communities amongst many others. The recommendations put forth in the focus group discussions were quantified, each one producing statistical significance across the group; with very negligible significant differences noted between MSM and TGW and across age groups, indicating mutual agreement on their collective importance. Conclusion and Recommendations The MSM and TGW are self-empowered communities and are acutely aware of their SRH needs. Hence community recommendations must lead policy change with focused research to fill existing gaps. Specialized training for healthcare professionals with a holistic approach including mental health care, strengthening of existing NGOs through government support, provision of individual insurance, increasing outreach to rural communities, and sensitization of the society and local leaders emerged as key recommendations. We further suggest an integrated, gender- transformative approach by strengthening existing medical curricula, training, insurance schemes and delivery models.

Background: Tenia solium (T. solium) parasite is a tapeworm that causes taeniasis and cysticercosis when ingested as viable cysts and eggs respectively. A greater burden of T. solium infection is felt in low and middle-income countries, within which it accounts for 80% of all cases of acquired epilepsy. In Rwanda, available reports suggest that T. solium cysticercosis is endemic and affect both humans and pigs. In addition, neurocysticercosis has been documented in people with Epilepsy (PWE) in the southern province of Rwanda where there is extensive pig husbandry. As a neglected disease, neuro/cysticercosis requires a multidisciplinary and multisectoral approach to be addressed. Health education has been shown to be one of the effective measures to inspire positive change in behavior and promote desired attitudes towards the eradication of neuro/cysticercosis. Methods: A cross-sectional mixed-methods study was carried out with the aim of evaluating the baseline knowledge and knowledge acquisition and retention of community health workers (CHWs) on different aspects of T. solium using a multiple-choice questionnaire. The knowledge was assessed with the same questionnaire at different time intervals in relation to a health education intervention which was conducted using “The Vicious Worm” education tool. In addition, a semi-structured interview guide was used to determine the perceptions of the participants regarding the health education tool used. The quantitative data was collected at three-time intervals, pre-intervention, immediately post-intervention and four weeks post intervention, and was analyzed using IBM SPSS Statistics for Windows, version 27 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics were used to describe the sociodemographic characteristics of the participants while Wilcoxon Signed Rank and logistic regression tests were used to determine the association among variables considering a confidence interval of 95% and a p value of < 0.05. Finally, a thematic analysis was carried out to analyze the qualitative data. Results: A total of 217 participants were recruited for this study. The participants were from Tare (40%) and Kibirizi (60%) sectors of Nyamagabe district in the southern province of Rwanda. Participants were composed of males (32%) and females (68%), aged between 22 and 68 years (median:45, IQR= 15 years). The participants came from three levels of educational background and most (71%) of them were those who had at least completed primary school. The baseline knowledge score showed a lower and significantly different overall median score (76.19%, IQR=14.28%) than both the immediate post-intervention median score (95.14%, IQR=9.52%) (p value < .001) and the median score four weeks after the intervention (95.14%, IQR=9.52%) (p value < .001). Immediately post-intervention, the participants from Kibirizi had a median score of 100%, an increase of 23.8% from their baseline (p value < .001), while those from Tare scored 95.2%, an increase of 23.8% (p value < .001). At follow-up, 4 weeks later, the overall median score was the same for both Kibirizi and Tare, 95.2% with no significant difference from the immediate post score (p value 0.119 and 0.212 respectively). There was performance improvement across all question categories, however, performance on neurocysticercosis was lower compared to other categories of questions. There was no independent variable found significant to influence the participants’ short-term knowledge acquisition and retention. The participants reported the tool to be user-friendly and educative. They expressed that they were challenged by the digital skills required to use the soft tool and recommended to be equipped with digital literacy and provided with digital devices to access the tool or else be provided with booklet forms of the tool. Conclusion: This study has shown gaps in knowledge regarding T. solium infections within rural Rwanda. The gap is wider in knowledge regarding neurocysticercosis than other T. solium infections knowledge. Health education using “The Vicious Worm” education tool has proven effective to provide short-term T. solium knowledge acquisition and retention to CHWs. If CHWs were digitally equipped or provided with a hard version of the tool, they would be more comfortable learning and transferring knowledge from it.

Background: There is an urgent need to adapt health systems to consider the interface between human, animal and ecosystem health, which converge in the One Health (OH) approach. Today, there are numerous global health challenges, including climate change, biodiversity loss, the globalization of disease spread, and food insecurity. These events negatively affect human health. Thus, medical doctors, particularly in Sub-Saharan Africa (SSA), should know about OH-related factors and the social determinants of health so that they can provide more holistic patient care. However, there is little research about OH awareness among medical practitioners in SSA. This study was thus completed to identify if and how medical education institutions from SSA integrate OH into their medical curricula. Methods: This mixed methods, cross-sectional study used purposive sampling to explore the comprehensiveness of OH integration into the curricula of SSA medical education institutions. Participants were sampled from accredited SSA medical education institutions and were either Deans, Administrators, or Faculty members with self-reported knowledge about their institutions’ medical curricula. Two data collection tools, survey questions and an interview guide, were used to gather participants’ insights. Questions focused on OH topics and competencies integrated into medical curricula, how they were integrated, the sufficiency of OH topic and competency integration, and associated benefits and challenges. Survey information was gathered using an online QualtricsXM survey and phone or online calls. To test for associations among quantitative variables, logistic regression and odds ratios were used, and thematic analysis was used for qualitative data. A comprehensiveness checklist guided the categorization of institutions’ OH content into “very sufficient,” “sufficient,” and “room for improvement” groups. Results: A total of 61 participants from 27 SSA countries completed the survey. Among these participants, 23 also completed a semi-structured interview. The overall response rate was 28.1%. The most common OH topic reportedly integrated into medical curricula was epidemiology (n=56, 93.3%). Regarding OH competencies, ethics and values were the most common (n=40, 66.7%). Interviewees commonly linked zoonotic/vector-borne diseases, collaboration, and research with OH. Based on the comprehensiveness checklist, most participants’ institutions (N=43) fall under the category of having “room for improvement” (N=37, 86.0%). The most commonly cited benefits of OH were “holistic patient care” and “provision of better health care services for all.” For the participants that integrated OH (N=43) and those that didn’t (N=18), they cited “not enough time” (n=23, 53.3%) and “lack of faculty knowledge” (n=16, 88.9%) as the biggest barriers to integrating OH, respectively. Conclusion: This study demonstrated gaps in OH integration into SSA medical curricula. Animal and environmental health experts are insufficiently involved in medical curricula development, and medical students still study in silos. This has contributed to having medical doctors who are not sufficiently prepared to address current global health issues affecting human health. Thus, there is an imminent need to train both medical teaching staff and future medical doctors to provide holistic patient care using the OH approach.