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Background Large scale physical distancing measures and movement restrictions imposed to contain COVID-19, often referred to as ‘ lockdowns ’, abruptly and ubiquitously restricted access to routine healthcare services. This study describes reported barriers and coping mechanisms to accessing healthcare among chronic care patients during the nationwide COVID-19 lockdown in Rwanda. Methods This cross-sectional study was conducted among chronic care patients enrolled in pediatric development, HIV/AIDS, non-communicable diseases, mental health, and oncology programs at 3 rural Rwandan districts. Active patients with an appointment scheduled between March–June 2020 and a phone number recorded in the electronic medical record system were eligible. Data were collected by telephone interviews between 23rd April and 11th May 2020, with proxy reporting by caregivers for children and critically ill-patients. Fisher’s exact tests were used to measure associations. Logistic regression analysis was also used to assess factors associated with reporting at least one barrier to accessing healthcare during the lockdown. Results Of 220 patient respondents, 44% reported at least one barrier to accessing healthcare. Barriers included lack of access to emergency care ( n  = 50; 22.7%), lack of access to medication ( n  = 44; 20.0%) and skipping clinical appointments ( n  = 37; 16.8%). Experiencing barriers was associated with the clinical program ( p  < 0.001), with oncology patients being highly affected (64.5%), and with increasing distance from home to the health facility ( p  = 0.031). In the adjusted logistic regression model, reporting at least one barrier to accessing healthcare was associated with the patient's clinical program and district of residence. Forty (18.2%) patients identified positive coping mechanisms to ensure continuation of care, such as walking long distances during suspension of public transport ( n  = 21; 9.6%), contacting clinicians via telephone for guidance or rescheduling appointments ( n  = 15; 6.8%), and delegating someone else for medication pick-up ( n  = 6; 2.7%). Of 124 patients who reported no barriers to accessing healthcare, 9% used positive coping mechanisms. Conclusion A large proportion of chronic care patients experienced barriers to accessing healthcare during the COVID-19 lockdown. However, many patients also independently identified positive coping mechanisms to ensure continuation of care - strategies that could be formally adopted by healthcare systems in Rwanda and similar settings to mitigate effects of future lockdowns on patients.

Background Understanding cultural perceptions of illness is crucial for effective healthcare delivery. This study examines the ethnomedical concept of ikirimi, a culturally recognized illness in Rwanda characterized by perceived uvula abnormalities, and its traditional management through uvulectomy. This study explores the cultural understanding of ikirimi , its perceived causes, symptoms, and treatments, as well as barriers to integrating modern healthcare. Methods An exploratory qualitative approach was employed, involving in-depth semi-structured interviews with eight participants: traditional healers, individuals who underwent traditional uvulectomy, and healthcare providers. A grounded theory approach which analyzes data in systematic manner to generate new theories was applied, with coding conducted in English after initial transcription and analysis in Ikinyarwanda to preserve Indigenous concepts. Results Participants described ikirimi as an illness affecting the uvula (named as akamironko or akamirabugari or agashondabugari in Ikinyarwanda), characterized by swelling, elongation, and pus-like discoloration. Reported symptoms included fever, difficulty swallowing, coughing, and weakness, with children identified as the most affected group. Traditional healers diagnosed ikirimi through visual inspection of uvular morphology and movement and treated it by cutting the affected part of uvula and is known as guca Ikirimi ‘traditional uvulectomy’. Barriers to integrating modern healthcare included skepticism about biomedical care, judgmental attitudes from providers, and communication gaps. Despite the prevalence of ikirimi , its biomedical correlates remain unclear, though participants associated it with severe throat illnesses such as tonsillopharyngitis. Conclusion The findings highlight ikirimi as a socially constructed illness with deep cultural roots, significant health implications, and persistent barriers to modern healthcare. Addressing these barriers requires culturally sensitive approaches that integrate Indigenous knowledge with biomedical practices. Future research should explore the biomedical correlates of ikirimi and foster collaboration between traditional and modern healthcare systems to improve patient outcomes.

Background The Mentoring and Enhanced Supervision at Health Centers for Mental Health (MESH-MH) program supports mental health care delivery by non-specialist, primary care providers in Rwanda to improve access to quality mental health care. After an initial pilot in one rural district, the program was scaled to support service delivery across two additional districts. We aimed to assess changes in symptoms and functioning outcomes among patients who received treatment at selected health centers supported by MESH-MH. We compare them with patient outcomes from the original pilot district. Methods We conducted a prospective cohort study among patients with mental health conditions and epilepsy who started treatment at ten health centers in the Rwinkwavu and Kirehe Hospital catchment areas between November 2020 and December 2021. We assessed patients’ symptoms using the 12-item General Health Questionnaire (GHQ-12) and daily functioning using the 12-item World Health Organization Disability Assessment Scale (WHO-DAS 2.0 Brief). We collected data at baseline, midline (on average, 71 days from treatment initiation), and endline (on average, 197 days from treatment initiation). We measured changes over time in outcomes and associations with the duration of treatment using Wilcoxon signed rank tests and linear mixed models. We compared findings with those of our previous study in the Burera district using linear mixed models and adjusting for possible confounding factors. Results Of 151 participants enrolled, primary diagnoses were epilepsy ( n  = 45, 29.8%), depression ( n  = 36, 23.8%), brief psychosis ( n  = 26, 17.2%), and schizophrenia ( n  = 20, 13.2%). The median GHQ-12 score improved from 24 (IQR: 18–30) at baseline to 11 (IQR: 5–17) at endline (median change: -12 [IQR: -19, -6], p  < 0.001). The median WHO-DAS Brief score improved from 21.8 (IQR: 13–30) to 6 (IQR: 3–15) (median change: -13 [IQR: -22, -4], p  < 0.001). The median number of days with having difficulties to carry out regular activities declined from 20 (IQR: 7–20) at baseline to 5 (IQR: 2–15) at endline (median change: -10 [IQR: -21, 0], p  < 0.001) with comparable significant reductions in the number of days where patients were less able to engage in usual activities. We consistently observed significant improvements when using linear mixed models and across patient diagnoses. The scale-up sites revealed slightly greater reductions in symptoms relative to Burera, the pilot site study, while they showed comparable improvements in functioning. Conclusions Our findings indicate that patients with mental health conditions and epilepsy who received treatment at health centers newly supported by MESH-MH experienced significant improvements in symptoms and functioning. These improvements were comparable to the outcomes seen in the initial pilot of MESH-MH. Scaling-up interventions like the MESH-MH model could help to decentralize and increase access to mental health services in Rwanda and other similar settings.

ObjectiveDuring the COVID-19 pandemic, community health workers (CHWs) served as front-line workers in the COVID-19 response while maintaining community health services. We aimed to understand challenges faced by Rwanda’s CHWs during a nationwide COVID-19 lockdown that occurred between March and May 2020 by assessing the availability of trainings, supplies and supervision while exploring perceived needs and challenges.Design and settingThis study was a mixed-method study conducted in three Rwandan districts: Burera, Kirehe and Kayonza.Main outcome and measureUsing data collected via telephone, we assessed the availability of trainings, supplies and supervision during the first national lockdown, while exploring perceived needs and challenges of CHWs who were engaged in COVID-19 response, in addition to their existing duties of delivering health services in the community.ResultsAmong the 292 quantitative survey participants, CHWs were responsible for a median of 55 households (IQR: 42–79) and visited a median of 30 households (IQR: 11–52) in the month prior to the survey (July 2020). In the previous 12 months, only 164 (56.2%) CHWs reported being trained on any health topic. Gaps in supply availability, particularly for commodities, existed at the start of the lockdown and worsened over the course of the lockdown. Supervision during the lockdown was low, with nearly 10% of CHWs never receiving supervision and only 24% receiving at least three supervision visits during the 3-month lockdown. In qualitative interviews, CHWs additionally described increases in workload, lack of personal protective equipment and COVID-specific training, fear of COVID-19, and difficult working conditions.ConclusionMany challenges faced by CHWs during the lockdown predated COVID-19 and persisted or were exacerbated during the pandemic. To promote the resilience of Rwanda’s CHW system, we recommend increased access to PPE; investment in training, supervision and supply chain management; and financial compensation for CHWs.

Background The burden of advanced cancer is rising in Africa. Cancer care involves complex conversations between providers, patients, and families. International guidelines recommend communication skills training for all cancer care providers, and patient-provider communication and training needs are strongly influenced by culture. As oncology and palliative care capacity expand in African settings such as Rwanda, participatory research is needed to culturally adapt communication skills training to best fit local contexts. Methods Guided by the Cultural Adaptation Process model, this study aimed to set the stage for adaptation and implementation of serious illness communication skills training in the Rwandan context. We conducted focus group discussions with interdisciplinary cancer care providers at Butaro Hospital in Rwanda to understand their communication training priorities and describe pertinent contextual factors. The focus groups were audio-recorded, transcribed, and analyzed using the framework method of thematic analysis. Results A total of 17 cancer care providers participated in one of three focus groups, including six physicians, seven nurses, two psychologists, and two social workers. Participants identified delivering bad news and responding to emotion as the most challenging aspects of clinical communication and the highest priorities for training. They expressed concerns about the psychological toll of difficult conversations on providers, advocating for future trainings to include burnout mitigation strategies. Participants described several key contextual factors that should inform adaptations of communication training for Rwandan cancer care. These include barriers common to low-resource settings as well as several local assets: interdisciplinary collaboration, dedicated clinical psychologists, group counseling sessions, peer support among patients, and strong community networks. Several findings will be directly applied to the design of an initial pilot communication training in Rwanda. Areas requiring further investigation and opportunities to broaden the scope of communication interventions beyond patient-provider encounters were identified. Conclusions This study sets the stage for adapted communication skills training in Rwanda that is guided by the priorities and recommendations of local cancer care providers. Several pertinent cultural and structural factors were identified that are common across diverse African settings. Therefore, our training adaptations, as well as the methodology used for adaptation, have the potential for widespread reach.

Background Family Medicine is a novel discipline in many countries, where the motivation for training and value added to communities is not well-described. Our purpose was to understand the reason behind the choice of Family Medicine as a profession, the impact of Family Medicine on communities, and Family Medicine’s characterizing qualities, as perceived by family doctors around the world. Methods One-question video interviews were conducted using an appreciative inquiry approach, with volunteer participants at the 2016 World Organization of Family Doctors conference in Rio de Janeiro. Qualitative data analysis applied the thematic, framework method. Results 135 family doctors from 55 countries participated in this study. Three overarching themes emerged: 1) key attributes of Family Medicine, 2) core Family Medicine values and 3) shared traits of family doctors. Family Medicine attributes and values were the key expressed motivators to join Family Medicine as a profession and were also among expressed factors that contributed to the impact of Family Medicine globally. Major sub-themes included the principles of comprehensive care, holistic care, continuity of care, patient centeredness, and the patient-provider relationship. Participants emphasized the importance of universal care, human rights, social justice and health equity. Conclusion Family doctors around the world shared stories about their profession, presenting a heterogeneous picture of global Family Medicine unified by its attributes and values. These stories may inspire and serve as positive examples for Family Medicine programs, prospective students, advocates and other stakeholders.

Community health workers (CHWs) play a vital role in spreading health-related information in low-and middle-income countries. Assessing their knowledge is crucial to combat health misinformation. To identify locally relevant COVID-19 and mental health-related information commonly held by CHWs and the misconceptions most prevalent in their communities in Haiti, Malawi, and Rwanda. A card-sorting activity was conducted with 39 CHWs from rural communities in Haiti (  = 13), Malawi (  = 12), and Rwanda (  = 14), between February and April 2023. The activity involved free sorting, true/false sorting, and card ranking to assess CHWs' knowledge, beliefs, and misconceptions surrounding COVID-19 and mental health. CHWs primarily categorized cards based on perceived truths, reflecting knowledge from trainings, media, and community beliefs. Overall, CHWs correctly identified 59% of true COVID-19 statements and 73% of false statements, with no statistical differences in COVID-19 knowledge rates among countries [correctly sorted as true:  = 0.421; correctly sorted as false:  = 0.128]. However, specific COVID-19 misconceptions varied across countries, such as beliefs about vaccine effectiveness and side effects. Mental health knowledge varied substantially across countries, with Haitian CHWs demonstrating the highest expertise in correctly identifying false mental health information [Haiti: median 86.0%; Malawi: median 21.0%; Rwanda: median 79.0%;  < 0.001)]. Significant misunderstandings about mental health causes and treatments were influenced by religious and spiritual beliefs. CHWs have substantial gaps in information about COVID-19 and mental health. Knowledge of areas of misinformation can differ between countries. Constructing country-specific educational messages to address these areas can better inform CHWs and improve health literacy.

The COVID-19 pandemic has disrupted health services worldwide, which may have led to increased mortality and secondary disease outbreaks. Disruptions vary by patient population, geographic area, and service. While many reasons have been put forward to explain disruptions, few studies have empirically investigated their causes. We quantify disruptions to outpatient services, facility-based deliveries, and family planning in seven low- and middle-income countries during the COVID-19 pandemic and quantify relationships between disruptions and the intensity of national pandemic responses. We leveraged routine data from 104 Partners In Health-supported facilities from January 2016 to December 2021. We first quantified COVID-19-related disruptions in each country by month using negative binomial time series models. We then modelled the relationship between disruptions and the intensity of national pandemic responses, as measured by the stringency index from the Oxford COVID-19 Government Response Tracker. For all the studied countries, we observed at least one month with a significant decline in outpatient visits during the COVID-19 pandemic. We also observed significant cumulative drops in outpatient visits across all months in Lesotho, Liberia, Malawi, Rwanda, and Sierra Leone. A significant cumulative decrease in facility-based deliveries was observed in Haiti, Lesotho, Mexico, and Sierra Leone. No country had significant cumulative drops in family planning visits. For a 10-unit increase in the average monthly stringency index, the proportion deviation in monthly facility outpatient visits compared to expected fell by 3.9% (95% CI: −5.1%, −1.6%). No relationship between stringency of pandemic responses and utilisation was observed for facility-based deliveries or family planning. Context-specific strategies show the ability of health systems to sustain essential health services during the pandemic. The link between pandemic responses and healthcare utilisation can inform purposeful strategies to ensure communities have access to care and provide lessons for promoting the utilisation of health services elsewhere.

ObjectivesWe aimed to describe access to food and symptoms of depression among patients with chronic diseases or their caregivers, and assess associated factors during the COVID-19 lockdown in rural Rwanda.DesignA cross-sectional study.Setting and participantsA stratified random sampling technique was used to recruit 220 patients enrolled in the HIV, non-communicable diseases, mental health, paediatric development clinic and oncology programmes in three rural districts of Rwanda.Outcome measuresTelephone-based interviews were conducted to collect data on the number of daily meals before and during the COVID-19, and depression was assessed using the Patient Health Questionnaire-9. We used logistic regression analysis to investigate factors associated with households reporting a reduction in daily meals and with the survey respondent reporting symptoms of depression.ResultsOf the participants, 19.1% reported a reduction in daily number of meals for either adults or children in their households during lockdown and 24.6% had depression. Reporting a reduction in daily meals was associated with the district of residence and estimated household’s monthly income. Self-reported depression was significantly associated with negative experiences during lockdown, including reporting feeling depressed or fear (AOR 4.82; 95% CI 2.08 to 11.21), loneliness (AOR 4.33; 95% CI 1.32 to 14.13), reduction in daily meals (AOR 4.15; 95% CI 1.56 to 11.00) and lack of access to healthcare (OR 3.29; 95% CI 1.32 to 8.23).ConclusionsOur findings suggest that significant reduction in access to food affected rural Rwandans with chronic diseases during COVID-19 lockdown, and the lockdown effect varied by household’s pre-pandemic level of vulnerability to food insecurity. Reduction in household meals, as well as other self-reported effects of the lockdown, were associated with worse psychological status of survey respondents. Economic and food support should be considered by governments and non-governmental organisations to protect those most vulnerable including patients with chronic diseases against the effects of pandemics and their associated containment measures.