MGHD 2024

Snakebite envenomation is a neglected tropical disease predominantly affecting poor rural farmers and their animals. In Sub-Saharan Africa, over 268,000 people are envenomed by snakes annually with an estimated 138,000 deaths and a burden of 1.03 million Disability Adjusted Life Years. Research on the burden of snakebites on animals is limited with one study reporting over 47% global case fatality among animals bitten by snakes. However, there is sale of SRs in agro- veterinaries in East Africa as SBE preventative measures despite undocumented efficacy and safety. This cross-sectional quantitative study aimed to understand the cost, safety, and appropriateness of snakebite treatments (STs) and snake repellents (SRs) sold in agro-veterinary wholesale outlets in East Africa. In total 78 agro-veterinary wholesale workers were interviewed, and online searches of STs and SRs were conducted in Google, Bing, and Yahoo search engines as well as popular online shops. Collected information included product ingredients, country of origin, target snake species, claimed efficacy, and respondent opinions on products' efficacy and market demand. While no antivenoms were documented, a total of seven inflammatory medication and 98 mechanical and chemical SRs were identified. The SR median cost of application to standard farm size in East Africa equated to at least 9.5 workdays, based on the international poverty line of $2.15 per day. On average, the safety of 88.1% of the SRs identified could not be concluded from a One Health perspective due to a lack of information on formulation and ingredient concentration. No products were found to have scientific proof of efficacy in repelling African snakes. The use of acaricides, insecticides, and disinfectants as SRs was also noted in Kenya and Tanzania. Overall, this study highlights the presence of inappropriate SRs and of unknown safety which pose safety concerns to humans, animals, and environmental health, and cause farmer income loss. Keywords: SBE, One Health, Agro-veterinary, Snake repellent, Snakebite treatment, Snake antivenom, Farmers

Background: Globally, every two minutes, a woman dies during pregnancy or childbirth, with 70% of these deaths occurring in low-middle-income countries (LMICs), particularly in sub-Saharan Africa. While Rwanda has made significant progress in reducing maternal mortality rates, challenges such as inadequate healthcare infrastructure and limited access to services in rural areas persist. Obstetric ultrasound, a vital tool for monitoring pregnancies, remains largely inaccessible at the community level, with only 47% of women in Rwanda receiving a recommended ultrasound before 24 weeks of gestation. To address this gap, Partners in Health (PIH), initiated the decentralization of obstetric ultrasound services to health centers in 2022. In low middle income countries (LMCIs) specifically in sub-Saharan Africa, maternal mortality is 70% of all the death that occurs globally Research Aim: This study aimed to assess the impact of the decentralization of obstetric ultrasound services in Kirehe District, Rwanda. It explored the demographic profile of clients utilizing ultrasound services, changes in maternal complications among high-risk pregnancies pre- and post-decentralization, and healthcare providers' experiences with the new service provision. Methods: The study used in-depth interviews (IDIs) with healthcare providers and a retrospective cross-sectional study with electronic medical records (EMR) and maternal logbooks. The qualitative part involved interviews with five healthcare providers from five randomly selected health centers. The quantitative part utilized retrospective data from one year before and one year after the decentralization of ultrasound services, analyzing 3,563 pregnant women’s records from Kirehe District Hospital and 600 records from five health centers post-decentralization. Results: Qualitative findings revealed three key themes: improved diagnostic capabilities and access to care, financial challenges for patients, and staffing and training issues. Healthcare providers reported enhanced ability to detect pregnancy-related complications and reduced referrals to district hospitals. However, the cost of ultrasound services (2,000 Rwandan Francs) posed a financial barrier, as it is not covered by community-based health insurance. Additionally, the limited number of trained staff and the need for ongoing training and mentorship were highlighted. Quantitative results showed that the median age of participants was 31.95 years, with most pregnancies classified as low risk (60.65%). The proportion of high-risk pregnancies did not significantly change post- decentralization (χ² = 1.193, p = 0.274). In health centers, most ultrasound users were in the 20-34 age group, with only 7% classified as high-risk pregnancies. The primary reasons for ultrasound visits were routine checks (86.5%) and suspected complications (10.3%). Conclusion: Decentralization of obstetric ultrasound services in Kirehe District improved access and diagnostic capabilities but did not significantly alter the prevalence of high- risk pregnancies. Financial barriers and staffing challenges persist, underscoring the need for policy adjustments to include ultrasound services in community health insurance and for continuous professional development of healthcare providers. Future studies should directly capture patient experiences and evaluate quantitative health system efficiency metrics to further understand the impact of decentralizing ultrasound services on maternal health outcomes.

Background: Non-communicable diseases (NCDs), particularly hypertension and type 2 diabetes, are emerging health burdens in low- and middle-income countries. According to the World Health Organization, NCDs contributed 50% of total deaths occurred in Rwanda in 2019. The recent Stepwise NCD survey done in Rwanda in 2022 revealed that hypertension and diabetes burden are on the rise with prevalence rates of 16.8% and 2.9% respectively. Despite growing trends of the diseases, there is limited evidence on the status of quality of care in the service delivery in Rwanda. This study aimed at evaluating quality of hypertension and type 2 diabetes care in eight Partners in Health (PIH) supported health centers in Rwinkwavu catchment area through assessing the adherence to the management protocols, availability of resources and their implications on level of disease control in those facilities. Methods: A facility based cross sectional study was conducted using 314 patient records enrolled in the period of January 2022 to April 2024 from eight PIH supported health centers in the Rwinkwavu catchment area of Kayonza district, Rwanda. Guided by Donabedian (1988) quality of care assessment framework, the study focused on each single component in three domains of quality of care. A data extraction tool was developed guided by existing management protocol of hypertension and type 2 diabetes in Rwanda. Data was extracted from Electronic Medical Records, and missing information was completed using patient files and registries at health centers. Resource inventory in the facilities was done using a tool programmed in Redcap. Data was downloaded to Excel. All data were cleaned before processing for analysis. Descriptive statistics were used to summarize socio-demographics, resource availability, compliance to the process of care, and level of hypertension and diabetes control. Bivariate analysis was done to assess the association between compliance and disease control, and the association between dependent variables with independent variables. All data analysis was done using SPSS (IBMv.20.0) and p-value set at 0.05. Results: The study population was predominantly female (69.7%) and aged 65 years or older (46.8%). Hypertension was more prevalent (85.7%) than diabetes (8.9%) or comorbidity of both conditions (5.4%). Overall adherence to recommended processes of care was low, ranging from 21% to 23% across disease types. While 100% of hypertensive patients and 55% of diabetic patients met the minimum eight of twelve recommended number of visits, there were significant gaps in specific follow-up care elements. Disease control was achieved in 54% of diabetic patients and 42.3% of hypertensive patients. Resource availability varied, with basic equipment universally available but specialized tools often lacking. Conclusion: This study reveals gaps in adherence to care processes for the management of hypertension and type 2 diabetes in primary healthcare facilities in Rwanda. While some aspects of care show promise, there is substantial room for improvement in adherence to comprehensive management protocols. These findings highlight the need for targeted interventions to enhance NCD care quality, including standardized tools for patients’ data storage, robust monitoring systems, financing for human resources, capacity building and innovative care delivery models.

Background: Preterm birth affects 13,4 million cases globally, presenting significant health and socioeconomic challenges. Addressing preterm birth’s underlying risk factors and causes, such as Preterm Premature Rupture of Membranes (PPROM) and Cervical Insufficiency (CI), is important. Although these conditions are manageable, they still contribute to high rate of preterm birth, especially in developing countries like Rwanda, where limited resources alter effective management. Studies on the lived experience of Skilled Birth Attendants (SBAs) are needed to understand how these conditions are managed. Objective: To explore skilled birth attendants’ lived experience in the management of PPROM and CI as risk factors for preterm birth in Rwanda. Methods: A qualitative study using phenomenological approach was conducted in five health facilities in Rwanda. Participants were SBAs working in gynaecology and obstetrics departments. After obtaining informed consent, 24 in-depth interviews were conducted using semi-structured interview guide. The interviews were recorded, transcribed, and translated into English. The transcripts were openly read, manually coded inductively and analysed thematically into codes and themes using Dedoose. Results: Result of the study underscores the lived experience of SBAs while managing PPROM and CI including the challenges they face and the foundational anchors of the management. Five major themes were identified, which were: “Effective Management requires collaborative care”, “Improved practice impacts patients’ outcomes and SBA’s emotions”, “Management guidance through knowledge and protocols”, “Lack of resources and patients’ factors challenge the management” and “Empowering communities and SBAs”. Conclusion: Interventions aiming to improve PPROM and CI management should focus on equipping healthcare facilities with adequate resources, up-to-date management protocols and providing continuous education and emotional support to SBAs.

Background: Cardiometabolic disease risks of pregnancy, such as HDP and GDM, increase the risk of developing chronic diseases later in life. FIGO developed a tool, the FIGO Pregnancy Passport aiming to facilitate screening and follow-up for women at risk for cardiometabolic diseases. However, the implementation of such a tool, especially in LMICs, remains limited. This study accessed healthcare workers’ acceptability of, and readiness to implement the FIGO Pregnancy Passport within MDH and evaluated the level of screening of cardiometabolic disease risk factors among women who delivered within the hospital, as compared to a modified FIGO screening method, between 15 May 2024 and 14 June 2024. Methods: We conducted a multi- method study: the quantitative portion employed patient and electronic medical record screening to evaluate the level of screening of cardiometabolic disease risk factors among women who delivered at MDH; the qualitative portion utilized FGDs and KIIs to assess healthcare workers’ acceptability of the FIGO Pregnancy Passport, and the necessary resources needed to implement the FIGO tool. Results Quantitative: The study screened 489 postpartum women, The modified FIGO screening tool identified cardiometabolic disease risks in 34% (n=165) of postpartum women, which was over eight times higher than the 4% (n=18) recorded in their electronic medical records (EMRs). While the most common FIGO-identified risk was family history of high blood pressure (33.5%, n=81), the EMRs didn’t record any family history of hypertension but indicated preeclampsia (38.9%, n=7) as the most common recorded risk. Stillbirth was the second most common risk identified by both the FIGO tool (17.8%, n=43) and the EMRs. The discharge summaries showed a percentage of postpartum care instructions (93.3%, n=456) of patients had at least one instruction, with breastfeeding (45.2%, n=221) and medication (38.4%, n=188) being the most common recommendations. However, the FIGO screening process resulted in over 25 times more recommendations for follow-up (33.9%, n=165) compared to the EMR discharge summaries (1.2%, n=6). Over half (53.6%, n=262) were categorized as Ubudehe Category 2. Qualitative: Three FGDs and two KIIs were conducted to assess HCP acceptability of, and resources required to implement the FIGO Pregnancy Passport. Three core themes emerged: 1) Healthcare providers viewed the management of patients with cardiometabolic disease risks of pregnancy as important, though practices for management varied; 2) The lack of knowledge about cardiometabolic disease risks of pregnancy and their relation to NCDs negatively impacts health delivery and health seeking behavior; 3) Even with resource or health system limitations, health care providers still considered and recommended ways to adapt the FIGO Pregnancy Passport to better fit the Rwandan health system context. Conclusion: The findings indicate that MDH has low screening levels, primarily focusing on assessing risks associated with current pregnancies which aligns with standard maternal care practices in LMICs. Screening for NCD prevention among women with cardiometabolic risks is limited, likely due guidelines not reflecting the connection between pre-pregnancy, pregnancy complications, and NCDs. HCPs are enthusiastic about utilization of FIGO Pregnancy Passport but face challenges like lab availability, screening capacity, HCP Knowledge and patient affordability, suggesting the need for system-level changes to address these gaps.

Background: Mental illnesses total 13% of the global disease burden. Effectively managing mental illnesses requires comprehensive treatment strategies that incorporate pharmaceutical, psychological, and social therapies. Patient retention in pharmacotherapy is one of the main factors that mental illness treatment outcomes depend on. In Rwanda, barriers and enablers for mental illness patient retention in pharmacotherapy among adults treated for mental illnesses have not been systematically synthesized to inform practice and policy. This study aims to quantitatively and qualitatively describe mental illness retention rates, and the experience of barriers, and enablers for patient retention in pharmacotherapy among adults treated for mental illnesses in Kayonza District in Rwanda. The primary outcome was mental illness patient retention to care defined as the attendance of at least four pharmacotherapy visits that were at least 90 days apart between January 1, 2023, and December 31, 2023. Methods: This was an explanatory sequential mixed methods study using the data of 343 adult patients with mental illnesses retrospectively extracted from the Electronic Medical Records (EMR) of the Rwinkwavu District Hospital (RDH) and eight health centers in its catchment area between January 1, 2023, and December 31, 2023. Fifteen purposively selected adults with mental illnesses and five conveniently selected mental health care-providers were qualitatively interviewed to describe patient experiences of potential barriers and enablers with patients’ psychiatric diagnosis as well as describe care-providers’ observations of potential barriers and enablers with patients’ experience of the potential barriers and enablers in Kayonza District between May – July 2024. Descriptive and thematic analysis was employed for quantitative and qualitative analysis respectively. Results: The data of 343 adults with mental illness was analyzed quantitatively. There were 197 (57.4%) females and 146 (42.6%) males with a median age of 33 years (IQR=21). Only 67/343 (19.5%) patient with mental illnesses were retain in pharmacotherapy treatment. 35/67 (52.25%) were female, and 32/67 (47.8%) were males. Patients’ age employment, and health facility had significant impact of patient retention (p-value < 0.05) while living with family had a marginal impact on retention in care (p-value 0.060). Key barriers included patients’ lack of understanding about their mental illnesses, patients’ forgetfulness, financial constraints, lack of family support and social stigma, and negative healthcare experiences. Important enablers were MH service quality, regular follow-ups, social support and active MH CHW services. Conclusion & recommendation: Barriers such as patients’ lack of understanding about their mental illnesses, patients’ forgetfulness, financial constraints, lack of family support and social stigma, and negative healthcare experiences and enablers such as MH service quality, regular follow-ups, social support and active MH CHW services are pivotal in improving patient retention rates in Kayonza District, Rwanda. We recommend comprehensive patient, family and societal mental health education program; strengthening community-based support systems; investing in rural healthcare facilities, patient-centered care with a focus on positive patient- provider relationships to improve patient and community understanding of mental illnesses and the importance of consistent pharmacotherapy.

Introduction: Biomedical equipment is crucial for maintaining high healthcare standards and ensuring timely patient care. Effective management of this equipment is vital, especially in low—and middle-income countries like Rwanda. This study assesses the availability and functionality of biomedical equipment and equipment management practices in the operating room (OR) and post-anaesthesia care unit (PACU) at Kabgayi, Kirehe, Kibogora, Butaro, and Kacyiru district hospitals in Rwanda. Methods: A multi-facility-based cross-sectional survey assessed biomedical equipment availability, functionality, and management in five district hospitals in Rwanda. Data was collected using i) a medical equipment checklist and ii) a hospital biomedical management practices checklist. Both tools were adapted from the policy and guidelines of biomedical equipment management practices in Rwanda. Key measures were summarized using descriptive statistics. Results: This study’s findings revealed that the five hospitals have a combination of 16 ORs, three PACUs, and 226 pieces of equipment. The overall availability of essential biomedical equipment in all hospital ORs was 45%. Only 5 of 19 equipment types meet the requirements set by the Rwanda health care service package list for public facilities. The overall functionality of the available equipment in the ORs and PACUs was high at 96%. However, it was noted that the government of Rwanda funded 42% of the available equipment, and the acquisition of another 42% of the surveyed equipment could not be tracked due to poor inventory management. The results also revealed an overall average adherence of 65.8% to biomedical equipment management practices across the hospitals surveyed. Conclusion: Our study found that the surveyed hospitals have low availability of biomedical equipment in their operating rooms (ORs) but a commendable functionality rate. The study also identified significant gaps in adherence to biomedical equipment acquisition and maintenance practices. Furthermore, it highlighted major issues with inventory management at the district hospital facility, as a large portion of the available equipment in the ORs and PACUs could not be properly accounted for. We, therefore, recommend that the MOH and partners pay closer attention to the availability of essential biomedical equipment while implementing a robust regular audit to assess the adherence to maintenance and management practices, including asset management. Keywords: Biomedical Equipment, Availability, Functionality, Adherence.

Purpose: This study explored the participation of people involved in livestock in One Health(OH) interventions targeting zoonotic disease control in Nyagatare District, Eastern Province, Rwanda. Also, the study mapped and characterized external livestock movements in Nyagatare District. Methods: A multimethod study employing qualitative and quantitative approaches were used. For the qualitative component, data collection involved in-depth interviews (IDIs), key informant interviews (KIIs), and focused group discussions (FGDs) targeting livestock farmers, veterinary officers, health and environmental officers, and community animal health workers. Participants were sampled through purposive and convenience approaches. Content analysis was conducted. For the quantitative component, a retrospective review of animal movement permits was used and centrality metrics were computed using Social Network Analysis (SNA). Results: The study found participation mainly in capacity building, community-based education about zoonotic diseases, environmental measures aimed at preventing zoonotic diseases, implementing measures that interrupt the route of zoonotic disease transmission, multi-sectoral collaboration, compliance with zoonotic disease prevention and control measures, and zoonotic disease surveillance and livestock vaccination. External livestock movement for 2023 demonstrated that the cattle markets supplied substantially to Nyarugenge, Gasabo, Rulindo, Bugesera, and Rusizi, districts. The cattle markets of Nyendo, Kirebe, Rwabiharamba, Ryabega, and Nshuli, and the districts of Bugesera, Kirehe, Rwamagana, Gatsibo, and Kicukiro presented the closest paths. The small ruminants only originated from the Kirebe market and supplied mainly Rubavu and Nyarugenge Districts. SNA showed Ryabega cattle market as the main departure point during the short rainy season. Nshuli, Nyendo, and Kirebe were markets during the long dry season and long rainy season. All markets were essential during the short dry season. Seasonal fluctuations for small ruminants were slightly varied between the wet and dry seasons. Conclusion: Community members play various roles in OH activities aimed at controlling zoonotic diseases, but their involvement is limited to disease prevention and control. There is a lack of community involvement in the planning/coordination of measures for helping them overcome zoonotic diseases. Cattle markets with high livestock movement can potentially contribute to the spread of zoonotic diseases across Rwanda.

Background: Urinary incontinence (UI), characterized by involuntary urine release, is a prevalent pelvic floor disorder affecting 20-30% of young, 30-40% of middle-aged, and up to 50% of older women globally, with a 21% prevalence in Sub-Saharan Africa. Contributors to UI include genetic factors, childbirth, and chronic conditions, leading to daily challenges such as leakage fears and social isolation. Despite its high impact, many affected women lack awareness of UI and available treatments, and significant knowledge gaps exist coupled with misconceptions among affected women. Treatment options include medication, surgery, and pelvic floor muscle training (PFMT). Across Africa, healthcare systems are enhancing governance frameworks and adopting digital solutions like WhatsApp and social media for professional collaboration, patient support, and health guideline dissemination. A scoping review demonstrates that women experiencing UI can effectively manage symptoms through digital technologies (DTs), particularly for PFMT. Aim: This study investigated the digital health educational needs, facilitators and barriers, and preferred digital health platforms for women with UI in Kigali. Method: It was a phenomenological qualitative study conducted across four hospitals in Kigali; Masaka Hospital, Rwanda Military Hospital, Kibagabaga Hospital, and King Faisal Hospital. IRB approvals were sought from the four hospitals and UGHE (Ref: UGHE-IRB/2024/295). Purposive sampling was used to select 20 women aged 20 to 70. Deductive and inductive coding were used, and the data was analyzed by thematic analysis. Result: The analysis identified four key themes: first, there are significant knowledge gaps about UI that necessitate multimodal education to address misinformation, misconceptions, and myths. Second, participants regularly use digital devices and the internet, appreciating their value, benefits, and affordability for accessing digital health information. Third, women with UI face barriers to digital health education due to distrust in the accuracy of online information and financial constraints in maintaining digital devices and internet services. Lastly, women with UI expressed a strong interest in receiving information through multimodal digital health education platforms. Conclusion: Many women misunderstood UI, confusing it with other conditions or believing it to be a normal part of aging, leading to delayed diagnosis, and treatment, and increased feelings of embarrassment and isolation. UI severely impacted their quality of life, causing social withdrawal, limited physical activities, financial strain, and emotional distress. Despite being digitally literate, they rarely sought digital health information about UI due to a lack of knowledge and limited understanding, financial constraints, and distrust of online sources. This study emphasized the need for accessible, trustworthy digital health education to bridge the knowledge gap, providing necessary information and support

Background: Childhood immunization is critical for preventing diseases and reducing child mortality globally. Despite Rwanda's high initial coverage, many children miss subsequent vaccinations, posing health risks. Electronic Health Records (EHR) like District Health Information System (DHIS2) e-Tracker aim to improve immunization by tracking schedules and managing vaccine inventory. This study evaluates DHIS2 e-Tracker's effectiveness and compares it with KURA, an android- based EHR system, to understand their impact on immunization program efficiency and healthcare provider satisfaction in Rwanda. Methods: We used a mixed-method observational study to assess the operational efficiency of the DHIS2 e-Tracker and KURA application for immunization at the Remera Heath Center. This involved evaluating data completeness and accuracy through record review. Additionally, retrieval time and report comprehensiveness were analyzed. To assess user experience, we conducted a System Satisfaction, and System Usability Scale (SUS) survey with five healthcare providers responsible for immunization services. Open-ended questions further explored their experiences and challenges with the system. Results: Findings from the review of 145 child immunization records showed comparable retrieval rates using child’s ID (p=0.235) but significant differences using child’s name (p<0.001). e-Tracker had lower completeness across essential data fields compared to KURA. We found a 66.7% staff satisfaction on KURA and 60% on e-Tracker. Qualitative analysis highlighted user desires for automated reminders, comprehensive reporting capabilities, and improved data control and training opportunities for e-Tracker. Integration with Civil Registration and Vital Statistics (CRVS) was a notable strength of e-Tracker. Conclusion: Overall, while both systems showed strengths, improvements in feature functionality, reliability, and System Usability are critical in both KURA and e-Tracker for enhancing immunization program efficiency and user satisfaction in Rwanda.

Background: Intimate partner violence (IPV) represents a significant global health challenge, affecting one in four women worldwide. This critical issue is associated with physical, psychological, and socioeconomic consequences particularly in Sub-Saharan Africa (SSA). The intersection of IPV with HIV/AIDS further increases vulnerability as PLHIV are at heightened risk of experiencing IPV. Rwanda records a high prevalence of both IPV and HIV, however, little is known about factors influencing the intersection of these phenomena. This study sought to address this gap by exploring the factors that contribute to IPV among a diverse group of PLHIV in Kayonza district, Rwanda. Method: An exploratory qualitative study was conducted between May and June 2024. A total of ten semi-structured interviews were conducted with PLHIV who have experienced IPV, and two FGDs were conducted with service providers who worked with PLHIV and survivors of IPV for over one year at the time of the study. This study explored the range of factors related to IPV in a diverse group of PLHIV. Purposive sampling and snowball sampling were used to recruit PLHIV and service providers, respectively. Key themes were drawn from semi-structured interviews and FGD transcripts using thematic analysis guided by the social-ecological model. Results: The findings highlighted four themes that exemplified the factors related to IPV among people living with HIV: 1) experiences of IPV in PLHIV are caused by general factors and by triggers directly related to their HIV status; 2) HIV-related stigma of various types is intimately tied to experiences of IPV and coping strategies; 3) traditional culture and gender norms shape PLHIV’s definitions and perceptions of IPV; 4) complex contextual factors regarding IPV reporting and fragmented service provision influence decisions regarding IPV-related coping strategies employed by PLHIV. Factors such as controlling behaviors, discordant HIV status, HIV-related stigma, gender norms, and barriers to coping strategies were identified as key factors related to experiences and perceptions of IPV in PLHIV. Women were thought to be more vulnerable to IPV by participants in connection to traditional gender norms, but men were also recognized as survivors of IPV. Coping strategies were dependent upon one’s social context and varied from silence and confiding in family and friends to reporting incidents to local authorities and law enforcement. The findings of this study may be used to improve interventions that address IPV among diverse groups of PLHIV in Rwanda. Conclusion: The study findings indicate gaps in the IPV reporting system and weaknesses in the provision of prevention efforts and services addressing IPV among PLHIV in Kayonza district. However, the findings also present the opportunity to implement effective interventions to improve existing reporting channels and interventions against IPV to reduce violence against PLHIV. Efforts to mitigate HIV-related stigma and misconceptions, address traditional gender norms, improve IPV reporting channels, and enhance the empowerment of marginalized groups have the potential to improve IPV among PLHIV with diverse identities.

Background: This study explored the acceptability, barriers and facilitators of Sexual and Reproductive Health (SRH) services provided by Community Health Workers (CHWs) to young people in Nyagatare District, Rwanda. The study aimed to address the critical gap in SRH services access among young people, a demographic that often faces significant challenges in obtaining necessary health services. A qualitative methods approach was utilized to comprehensively understand how young people perceive CHW SRH service delivery and its impact on the young population. Methods: The methodology consists of conducting 19 in-depth interviews with young people aged 15-24 years along with 4 focus group discussions with 6 key informants from the health sector and 24 Community Health Workers (CHWs) operating within Nyagatare District. Specifically designed data collection tools were utilized to gather comprehensive information on the participants' experiences, perceptions and suggestions for enhancing sexual and reproductive health (SRH) services provided by CHWs to young people. Results: Key findings reveal that 63.1% of young people had utilized SRH services before the interviews, with a majority of 84.2% being female participants. While CHWs are generally well- received by young people, barriers such as cultural beliefs, lack of privacy, and inadequate training and resources hinder the effective delivery of SRH services. Facilitators identified include the importance of involving young people in designing and implementing SRH programs, and ensuring that services are youth-friendly and meet their specific needs. Additionally, having CHWs well-stocked with necessary commodities was crucial, as young people prefer providers who can meet their needs without redirecting them elsewhere. Adolescents' ability to access healthcare services also depended on the physical availability of these services in the facilities. Recommendations for policy and practice include increasing investment in CHW training, policy reform, enhancing privacy measures and promoting community awareness to combat cultural stigmas associated with SRH. Conclusion: This research underscores the vital role of CHWs in bridging the gap in SRH services for young people in Nyagatare District. Addressing the identified barriers and leveraging the facilitators can significantly improve the accessibility and quality of SRH services, ultimately contributing to better health outcomes for the youth population. Future studies are suggested to focus on the long-term impact of these interventions and explore the scalability of successful strategies in other regions.

Background: Orofacial clefts pose significant challenges including feeding difficulties, respiratory issues, hearing loss, dental problems, and psychological impacts on affected children. Despite the knowledge that timely access to surgical care for children with clefts is essential for the children’s outcomes, there are still cases of children who present late for cleft surgeries. Considering insufficient information about the factors influencing these late presentations, this study aimed to explore the factors influencing delays in cleft surgery among children with cleft deformities in Rwanda, using a four-delay framework: seeking, reaching, receiving, and remaining in care. Methods: This phenomenological qualitative study was conducted in Operation Smile’s surgical program hospitals (CHUK, Kibungo, Kibuye, Ruhengeri, Rwinkwavu, Gisenyi, and Bushenge). A total of 29 In-depth interviews were conducted with 15 caregivers of children with cleft deformities and 14 healthcare providers who provide cleft care in Operation Smile’s surgical camps. Purposive sampling was used to recruit study participants, and the sample size was guided by theoretical saturation. Thematic analysis was done inductively using MAXQDA software version 24. Results: The analysis generated 19 subthemes and 6 major themes. The themes included: (1) factors influencing timely/delay in seeking care, (2) factors influencing timely/delay in reaching care, (3) factors influencing timely/delay in receiving care, (4) factors influencing timely/delay in remaining in cleft care, (5) Caregivers’ satisfaction toward cleft care received by their children, and (6) emotional, psychological, and family challenges faced by caregivers. The results revealed that lack of awareness about clefts among caregivers, and cultural norms influenced delay in seeking care. Transport factors such as poor road conditions and long-distance travel influenced delays in reaching care. Nutritional deficits attributed to poor weight gain, and frequent illnesses were physiological factors influencing delay in receiving care. Insufficient cleft care workforce including plastic surgeons, pediatric anesthesiologists, nutritionists, mental health specialists, speech therapists, and orthodontists, was a critical factor influencing delay in receiving and remaining in care. Additionally, findings revealed that caregivers of children with cleft deformities experienced emotional, psychosocial, and economic challenges and family conflicts. Despite these challenges, support services such as coverage of medical and transport costs, and provision of nutritional supplements were beneficial for timely care. Conclusion: The result of this study sheds light on the factors influencing delay in cleft surgeries in Rwanda and highlights the need for holistic programs that enhance comprehensive care of children with cleft deformities, such as educating parents, training healthcare professionals, increasing public knowledge about cleft deformities, causes, and management. The results highlighted the need for mental and social assistance for these children and their caregivers. Caregivers and healthcare providers offered critical insights about the success and challenges of cleft care in Rwanda, hence it is important to consider these perspectives when developing cleft care programs and national surgical plans.

Background: Globally, more than 121 million unintended births occur each year, and at least 10 million involve adolescents in low-income countries. In Rwanda, teenage pregnancies have grown from 19,000 in 2020 to 23,000 in 2021, with more unreported cases due to cultural silence combined with social norms. However, there exists a close association between unintended pregnancy and GBV in Rwanda which contributes to family conflicts.(Rurangirwa et al., 2017). Therefore, the Ingo z'amahoro project was implemented by Haguruka to mitigate conflicts between young unmarried mothers and their parents while addressing GBV through intergenerational dialogues. There is no previous study done to explore the impact of this project in mitigating conflicts between young unmarried mothers and their parents. The Intergenerational Transmission of conflict theory is used in this research to show how changes in factors like parental involvement and conflict resolution techniques affect and are affected by the empowerment of young unmarried mothers over time. This study sought to explore the impact of intergenerational dialogue, in the Ingo z’Amahoro project in resolving intergenerational conflicts in Musanze and Gasabo districts of Rwanda by July 2024. Specifically, by investigating the perceived effectiveness of intergenerational dialogues in young unmarried mothers and their parents. Methods: A qualitative exploratory design was used for this study. In-depth interviews were conducted using semi-structured interview guides, and 32 participants were recruited through the purposive sampling method. They comprised 12 young unmarried mothers, 12 parents, and 8 key informants including 4 community facilitators, 2 district officers, and 2 local community leaders at cell level in the Ingo z’Amahoro project. The study had ethical approval with reference number Ref: UGHE-IRB/2024/301 and participants gave voluntary consent. Interviews were conducted in the vernacular Kinyarwanda. Transcription and translation were performed in English. The transcripts were deidentified and coded inductively and deductively. Data analysis was conducted using thematic analysis with the assistance of Dedoose software. Results: Three themes emerged from this study. These themes, the perceived benefits of intergenerational dialogues by young unmarried mothers and their parents, socioeconomic setbacks that would hinder effective participation in the dialogues, and methods for integrating the project to guarantee its sustainability or preferred recommendations of what needs to be done otherwise to ensure the effectiveness of the intervention in the future. Considering teenage pregnancy, these findings offer a nuanced perspective of the project's influence on reducing intergenerational conflicts and adopting family and community resilience. Conclusion: Through organized intergenerational dialogues between young unmarried mothers and their parents, the Ingo z' Amahoro project has become recognized as a crucial effort in promoting understanding and reconciliation between young unmarried mothers and their parents. Efforts must concentrate on enhancing long-term support and expanding community involvement, consequently perpetuating favorable family relationships and enduring reconciliation.

Background: Cancer is a significant contributor to the global burden of non-communicable diseases. The International Agency for Research on Cancer (IARC) reported approximately 19.3 million new cases worldwide in 2020. In sub-Saharan Africa, over 800,000 new cancer cases were reported in 2020, of which breast cancer was the second leading after cervical cancer. The Butaro Cancer Center of Excellence (BCCOE) has been pivotal in providing comprehensive cancer care in Rwanda. However, there is limited research on the post-surgical experiences of Rwandan breast cancer patients following mastectomy. This study aims to explore these experiences, identify challenges, and understand coping mechanisms to enhance post mastectomy care and support. Methods: This qualitative, phenomenological study was conducted at BCCOE in Rwanda. The study employed in-depth interviews with adult female breast cancer patients attending post-surgical check-ups or receiving chemotherapy between April 30 and June 1, 2024. Participants were selected through simple random sampling from a patient database, ensuring inclusion criteria were met. Data collection involved semi-structured interviews using a guide developed from relevant literature, translated into Kinyarwanda for accuracy. Interviews were conducted in private settings, recorded with consent, and lasted 45-60 minutes. Transcripts were analyzed using thematic analysis and MAXQDA software was used to code and organize themes. The validity of the analysis was achieved through researcher triangulation. Data were stored securely, maintaining participants' anonymity and confidentiality. Ethical approval was obtained from the UGHE Institutional Review Board. Results: The study's findings are organized into seven thematic areas, illuminating the multifaceted challenges faced and coping mechanisms employed by post mastectomy cancer patients. Participants reported profound emotional distress concerning body image and self-perception. Many struggled to sustain their previous occupations due to physical limitations and encountered complexities in navigating healthcare and social dynamics. The impact extended to strained relationships with family and friends, highlighting significant interpersonal challenges. Coping strategies predominantly involved spiritual faith and seeking support from close relationships and community networks. The themes developed included 1. Emotional experience and body image and self-perception following mastectomy 2. Need for empathetic interaction and emotional support 3. Post mastectomy, individuals often face challenges continuing with their previous occupations 4. Navigating Healthcare and Social Dynamics 5. Mastectomy significantly impacts relationships with family and friends, often creating a strain that challenges the dynamics of family relationships and friendships 6. Coping with life after mastectomy 7. Support networks positively enhance the experiences of breast cancer patients after mastectomy and are essential in the recovery journey. Conclusion : The participants faced challenges including difficulties with follow-up visits due to long distances and high transport costs, and loss of previous occupations due to post mastectomy body changes. Stigma and misconceptions also emerged as pervasive issues. Therefore, there is a need for decentralized cancer care to facilitate local access to medication. Enhancing support programs to alleviate financial burdens, dismantle misconceptions around cancer, and establishing social support groups can emphasize the importance of comprehensive care strategies in improving the well-being of breast cancer patients after mastectomy.

Background: Adolescent sexual and reproductive health (SRH) is a global challenge, particularly in low- and middle-income countries (LMICs) where 90% of the 1.2 billion adolescents reside (WHO, 2024). In Sub-Saharan Africa, adolescent birth rates are high, with many unintended pregnancies ending in unsafe abortions (UNICEF, 2024; Sully et al., 2020). Despite Rwanda's efforts to improve adolescent SRH through national strategic plans and youth- friendly health facilities, utilization remains an issue, particularly in the Gatsibo district (MOH [Rwanda], 2018, Gender Monitoring Office, 2020). This study explores adolescents' experiences with SRH services utilization to inform targeted interventions and policies in Rwanda. Methods: A qualitative phenomenological study was conducted in the Kabarore sector, Gatsibo district. In-depth interviews (IDI) were conducted with seventeen adolescents consisting of 10 female and 7 males aged 10-19 years old. Thematic analysis was used to identify key themes and subthemes related to barriers and facilitators to SRH service utilization. Results: Five major themes emerged from the analysis: 1) Cultural norms and religious beliefs along with a lack of open communication with parents deter adolescents from seeking SRH services; 2) Adolescents’ insufficient knowledge and negative perceptions significantly limit their SRH service utilization; 3) Unfriendly SRH services provided by judgmental HCP heavily discourages adolescents from seeking SRH services; 4) SRH commodities were often unavailable, inaccessible, and inadequate infrastructures and 5) Effective SRH interventions/programs and strong peer support positively influences adolescents' utilization of SRH services. These findings draw attention to the lived experiences of adolescents and emphasize the importance of addressing these barriers to enhance SRH service accessibility and quality. Conclusion: This study highlights the complex interplay of factors affecting adolescents' utilization of SRH services in Gatsibo District. The findings underscore the need for multifaceted interventions addressing knowledge gaps, negative perceptions, and systemic barriers while leveraging positive peer influence and effective SRH programs. These insights can inform policy and practice to improve SRH service utilization among adolescents in similar settings.

Background: Podoconiosis is a highly preventable but neglected disease caused by prolonged barefoot exposure to volcanic soil. It is characterized by disabling lower limb swelling which is managed through cost-effective home-based management (HBM). This includes regular foot washing with clean water and soap, and consistent use of protective footwear highlighting the critical role of accessible WASH in effectively managing and preventing podoconiosis. However, it has been evident that some patients do not adhere to HBM but the reason is unknown. Therefore, This study explored podoconiosis patients' experiences in accessing WASH and identified the human, animal, and environmental barriers and facilitators of HBM in the Butaro sector. Methods: In this qualitative phenomenological study, in-depth interviews with podoconiosis patients were conducted and supplemented by observation and photographs. To identify study participants, all households in Butaro were screened. From the probable cases identified, a random selection was conducted, stratified by gender. Only those confirmed to have podoconiosis were invited for the interview. Transcripts were inductively coded using Dedoose (version 9.0.80) and analyzed through thematic analysis. Results: 26 interviews were conducted in all five cells of the Butaro sector. Most participants were female (61.5%), farmers (53.8%), livestock owners (57.7%), and 92.3% had uncovered mud floors. Limited knowledge about podoconiosis, distant water sources, and lack of fitting shoes were overarching responses. Additionally, participants expressed encountering significant barriers to practicing HBM, including physical limitations, poverty, and stigma, which hindered their access to WASH and HBM essentials. However, social support and the seasonal variations facilitated access to water and enabled HBM. Animal waste generated income enabled the participants to buy essential items to practice HBM. Conclusion: These findings highlight the impact of socioeconomic factors and WASH accessibility on podoconiosis management. Addressing these challenges through multisectoral collaboration and tailored interventions can lead to broader public health improvements and contribute to poverty alleviation by empowering affected communities with the tools and knowledge needed for effective HBM.

Background: Worldwide, blood malignancies account for 10% of cancer cases. Early detection and treatment increase the survival rate for cancer patients. The symptoms of blood malignancies include weight loss, loss of appetite, and feeling weak. This makes it difficult for healthcare providers at health center level to detect and refer patients early. BCCOE provides diagnosis and treatment services for cancer. This study aimed to explore experiences and initial health-seeking behaviors of patients with blood malignancies at BCCOE who sought care from a traditional healer for the same illness. Methods: A qualitative phenomenological study was conducted. In-depth interviews were conducted with patients with blood malignancies at BCCOE. Thematic analysis was used to develop themes. Results: Twelve respondents were interviewed. Our results highlighted five themes that depict the experiences for patients with blood malignancies and health-seeking behaviors. 1) Accessibility barriers to health facilities and healthcare services push patients with blood malignancies to seek care from traditional healers 2). The care-seeking pattern is influenced by the nature of the illness, beliefs, community, family, and friends 3) Frequent visits to health facilities and misdiagnosis lead patients with blood malignancies to seek care from traditional healers. 4) Seeking care concurrently from traditional healers and conventional medicine delays diagnosis and treatment. 5. Patients with blood malignancies seek care from conventional medicine after realizing that traditional healers are unable to treat their illness. Conclusion: The findings of this study highlight important changes needed to improve health outcomes for patients with blood malignancies at BCCOE. Patients highlighted system barriers, reasons they sought care from traditional healers, and factors influencing health-seeking behaviors. Therefore, it is critical to consider training healthcare providers at the health center on the symptoms for blood malignancies and collaboration between traditional healers and medical professionals to improve cancer care.

Background: Worldwide, blood malignancies account for 10% of cancer cases. Early detection and treatment increase the survival rate for cancer patients. The symptoms of blood malignancies include weight loss, loss of appetite, and feeling weak. This makes it difficult for healthcare providers at health center level to detect and refer patients early. Butaro Cancer Center of Excellence(BCCOE) provides diagnosis and treatment services for cancer. This study aimed to explore experiences and initial health-seeking behaviors of patients with blood malignancies at BCCOE who sought care from a traditional healer for the same illness. Methods: A qualitative phenomenological study was conducted. In-depth interviews were conducted with patients with blood malignancies at BCCOE. Thematic analysis was used todevelop themes. Results: Twelve respondents were interviewed. Our results highlighted five themes that depict the experiences for patients with blood malignancies and health-seeking behaviors. 1) Accessibility barriers to health facilities and healthcare services push patients with blood malignancies to seek care from traditional healers 2). The care-seeking pattern is influenced by the nature of the illness, beliefs, community, family, and friends 3) Frequent visits to health facilities and misdiagnosis lead patients with blood malignancies to seek care from traditional healers. 4) Seeking care concurrently from traditional healers and conventional medicine delays diagnosis and treatment. 5. Patients with blood malignancies seek care from conventional medicine after realizing that traditional healers are unable to treat their illness. Conclusion: The findings of this study highlight important changes needed to improve health outcomes for patients with blood malignancies at BCCOE. Patients highlighted system barriers, reasons they sought care from traditional healers, and factors influencing health-seeking behaviors. Therefore, it is critical to consider training healthcare providers at the health center on the symptoms for blood malignancies and collaboration between traditional healers and medical professionals to improve cancer care.

Background: The prevalence of neglected tropical diseases (NTDs) is steadily rising in sub- Saharan Africa (SSA). NTDs are being addressed under NTD programs, a sub-unit of the Ministries of Health. NTDs need an integrated approach to supplement current interventions such as Mass Drug Administration (MDA). Considering the human, animal, and environmental interface of NTDs, the One Health strategy is recommended for NTD programs by the Quadripartite organizations. However, One Health's uptake into NTD programs is unknown. This study was completed to assess how One Health is being integrated into NTD programs across SSA. Methods: This quantitative study used purposive sampling to assess the integration of One Health into NTD programs. NTD program managers across SSA were selected to participate in this study. A study tool to assess how One Health is being integrated was developed and adopted from previous studies on One Health. Both online surveys and phone calls were used to gather responses. The four integration criteria used were: interdisciplinary and multisectoral collaboration; policies, government involvement, and research and data/information sharing. This study was conducted in English, French, and Portuguese. Results: This study identified 50 countries with NTD programs, and 47 contacts of participants were established. Twenty-nine participants completed the survey, a response rate of 61.70%. The scores from 39 questions were used to determine the level of One Health integration. The integration score of NTD programs was moderate (54.66%). Funding constraints (93%) were identified as the barrier while an integrated approach to control and prevent NTDs (82.70%) was identified as an opportunity for integration. Conclusion: This study indicated moderate integration of One Health into NTD programs. Given the moderate integration and barriers such as financial constraints due to inadequate government funds for NTD programs, governments need to take ownership to promote the uptake of One Health into NTD programs