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The 1998 UNESCO World Conference on Higher Education in Paris recommended that global higher education institutions should internationalize and reduce inequalities between developed and emerging countries. Since then, universities strive to incorporate an international dimension in their service. The aim was initially guided by the 20th century understanding of internationalization being just, fair, and an equitable process that promotes peace and mutual understanding. However, under the influence of the General Agreement on Trade in Services and competition, internationalization changed focus and became less inclusive. This paper explores inclusive international education in East Africa using narrative review methodology. Findings suggest that rather than promoting access and equity in higher education, internationalization, for example, excludes economically disadvantaged, disabled, and adult learners. Thus, in addition to internationalization at home, inclusive internationalization abroad strategies should be devised. Internationalization of higher education is more valuable if it translates into fair, just, and peaceful social systems.

Amid a rise of misinformation worldwide, this paper examines digital misinformation literacy as it relates to COVID-19 news in East Africa. The study is grounded in inoculation theory and contributes to the body of scholarship examining misinformation literacy beyond the Western world. Data came from a comparative, cross-national survey in Kenya, Uganda and Rwanda (N = 3,203), making this the largest known empirical investigation into digital misinformation literacy in the region within the context of a pandemic. Paper surveys were distributed throughout all three countries in 2021. The data revealed differences in actual and perceived misinformation literacy levels. Kenyans and Rwandans were better at detecting false COVID-19 statements in the media, whereas Ugandans were better at detecting true messages. Similarly, Kenyans' and Rwandans' perceived levels of digital misinformation literacy were higher than Ugandans'. Regarding perceived exposure to COVID-19 information, Kenyans felt they were exposed to fake COVID-19 news online more often than Ugandans, who felt more exposed than Rwandans. This research contributes to the growing literature on digital misinformation literacy, an area which isn't significantly studied in many world regions, especially in Africa. [ABSTRACT FROM AUTHOR]

This study compares an ideal model of a sustainable research institution and the dominating model used by Sida. It uses a complementary capacity building (CCB) model aimed to promote an improved research culture for strengthening the sustainability of research partnerships in economics and management disciplines. This study uses bibliometric data to show post-graduation publication results from graduated Ph.D. students from the Sida supported research partnership in Rwanda and data from public records to show results from the implementation of the CCB model in the same country. The results show an increased publication activity among a significant proportion of the faculty members targeted by the CCB model and its contribution to improved research culture. Based on the evidence, the paper provides some recommendations to induce improvements in outcomes, including activities promoting a more active research culture in research partnerships with sub-Saharan African institutions.

This study examined the social and spill-over benefits as motivating factors to investment in formal education in selected countries in Africa. The paper had three objectives, namely) to profile the key statistics of formal schooling; ii) examine the formal education and iii) link national goals of education with expectations in Ghana, Kenya and Rwanda. The major contention of the paper is that investment in education is not a matter of random choice but rather an imperative led by the fact that education holds returns and externalities to the largest society. Authors reviewed theory of human capital, local and international publications on social and spill over benefits of education focusing on Ghana, Kenya and Rwanda. The analysis of government policies and other publications from these three African nations have shown that education is considered as a key sector in these developing nations. Nevertheless, the researchers found out that mostly only primary and secondary education are distinctively accorded considerable public financial resources which might be associated with the countries limited financial ability, competitive needs, national and global trends. However, the fact that Ghana, Kenya and Rwanda strive to become democratic, self-reliant and middle income nations by conquering long terms set visions in which caliber manpower, welfare, self-employment, reduced social inequalities, increase in average income, knowledge based society, ICT driven and sustainable economy are key characteristics; it is imperative to invest substantially in TVET and higher education. It is also recommended that Ghana, Kenya and Rwanda put in place strong institutions that objectively, effectively and rationally ensure the efficient use of all available resources towards maximum educational outputs.

With the growing demand for tertiary education, especially in Africa, the transformation of contact universities to dual-mode institutions is critical. However, conventional universities have had limited success establishing the dual-mode delivery stream. This paper assesses barriers to adoption and implementation of open and distance learning (ODL) in conventional higher education institutions in Cameroon, Kenya and Rwanda by applying a framework on innovation adoption to case studies of ODL in higher education in these countries. This qualitative meta-study shows that the transition to dual-mode is not systematic and that there are various barriers, ranging from national policy and funding; infrastructure, organisational structure and capacity; complexity and cost of ODL; as well as student and staff skills and perceptions, which have impeded adoption. Based on the findings, this paper makes recommendations for implementing ODL in existing conventional universities. Cases of successful transition to dual-mode are provided.

This paper describes the contribution of the Tuning Methodology toward harmonisation of undergraduate mechanical engineering programmes in Africa. This methodology is an interactive process in which academics develop high quality curricula and learning standards for students through the identification of generic and subject specific competences in consultation with employers, students, graduates, peers and other stakeholders involved in Mechanical Engineering higher education. The current Tuning process involves academics in 11 universities drawn from across Africa. The aim is to collaboratively contribute to revitalizing and reforming Mechanical Engineering higher education in Africa to make it more responsive to Africa's developmental needs. The results so far show that such a project is not only highly feasible but also holds promise for establishing compatible academic structures and reference standards across Africa, which would facilitate student and staff mobility as well as enhance cooperation not only among African academic institutions, but also between African institutions and those in the rest of the world. Eighteen generic competences and nineteen mechanical engineering-specific competences are developed, analysed and synergised to form a meta-profile that will inform the next phase of the project, which is the actual curriculum development. This activity is part of "Tuning Africa" project, which is funded through European Union-African Union collaboration.

Purpose: In developing countries, local buyers often rely on relational contracting based on reciprocity and trust. This paper analyzes relational contracting and global value chain (GVC) governance by focusing on how domestic and foreign coffee exporters in Rwanda confront challenges. Design/methodology/approach: Semi-structured interviews were conducted with 25 representatives of Rwandan private, Rwandan cooperative-owned and foreign exporters, and four coffee sector stakeholders. Findings: Foreign firms export most Rwandan coffee, and local exporters express concerns about their ability to compete. Rwandan exporters face challenges accessing capital, competing with foreign firms and managing high transaction costs. They use relational contracts to reduce transaction costs, and they benefit from a monopsony zoning regulation that reduces competition. Foreign exporters face regulatory challenges: a government-set coffee price and the zoning regulation. They vertically integrate to reduce costs and lock in suppliers through prefinancing. Research limitations/implications: Future research should analyze differences between local and foreign exporters in other contexts to advance understanding of the different challenges faced and contracting approaches used. Originality/value: Few GVC governance studies address the role of relational contracts in contexts where enforcement is costly. Considering relational contracts within GVCs can improve value chain analysis, specifically in the developing countries where many GVCs start. [ABSTRACT FROM AUTHOR]

In this data paper, we present a specimen-based occurrence dataset compiled in the framework of the Conservation of Endemic Central African Trees (ECAT) project with the aim of producing global conservation assessments for the IUCN Red List. The project targets all tree species endemic or sub-endemic to the Central African region comprising the Democratic Republic of the Congo (DR Congo), Rwanda, and Burundi. The dataset contains 6361 plant collection records with occurrences of 8910 specimens from 337 taxa belonging to 153 genera in 52 families. Many of these tree taxa have restricted geographic ranges and are only known from a small number of herbarium specimens. As assessments for such taxa can be compromised by inadequate data, we transcribed and geo-referenced specimen label information to obtain a more accurate and complete locality dataset. All specimen data were manually cleaned and verified by botanical experts, resulting in improved data quality and consistency. [ABSTRACT FROM AUTHOR]

Introduction: timely access to safe cesarean section (c-section) delivery can save the lives of mothers and neonates. This paper explores how distance affects c-section access in rural sub-Saharan Africa, where women in labor present to health centers before being referred to district hospitals for surgical care. Methods: this study included all adult women delivering via c-section between April 2017 and March 2018 in Kirehe District, Rwanda. We assessed the association between travel times and village-level c-section rates. Results: the estimated travel time from home-to-health center was 26 minutes (IQR: 13, 41) and from health center-to-hospital was 43 minutes (IQR: 2, 59). There was no significant association between travel time from home-to-health center and c-section rates (RR=1.01, p=0.42), but the association was significant for health center-to-hospital travel times (RR=0.96, p=0.01); for every 15-minute increase in travel time, there was a 4% decrease in c-sections for a health center catchment area. Conclusion: in the context of decentralized health services, minimizing health center to hospital referral barriers is of utmost importance for improving c-section access in rural sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to analyze the social institutions of trust, accountability and corporate shared value in creating an enabling environment for private sector investment in African agricultural and food systems. Design/methodology/approach: This paper uses mixed methods. A value chain framework models interactions among stakeholders in the agriculture, agribusiness and food sectors. The social institutions of accountability and trust are introduced into the model, followed by a Rwanda premium coffee value chain case study. Findings: The conceptual and case study results show that best practices can increase smallholder farmer, agricultural service provider, financial intermediary, and food processor investments in and benefits from the agriculture sector. Research limitations/implications: Further research is needed on the economic foundations of development cooperation based on trust, accountability and shared values, best practices and the link with desired societal outcomes, such as the sustainable development goals. Social implications: Mutual accountability processes, as they are maturing in Africa, are at the cutting edge of creating processes where multiple stakeholders, including agribusiness, can come together to make joint commitments to a shared development agenda, and where stakeholders hold themselves and others accountable for meeting these commitments. Originality/value: This is the first paper to bring together cutting-edge advances in corporate shared values, trust and accountability in the context of African agricultural and agribusiness development. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to outline the S&T and innovation policy challenges that Rwanda is experiencing in building a knowledge-based economy and draw some more general lessons for African countries.Design/methodology/approach The approach is based on methodological framework of country reviews used by international organizations in the field of science, technology and innovation policies.Findings The paper presents government policies that have been decisive for the good performance of the country in rebuilding its economy and society since the genocide (1994). It highlights the policy measures that have been taken in the fields of education, information and communication technologies, industry, science and so on with a view to put the country on a knowledge-driven development process. It pinpoints the need for more proactive policies to stimulate the diffusion of new technologies and innovation throughout the economy and the different sectors, including agriculture which employs still 80 percent of the population.Research limitations/implications The paper is based on a short field mission (conducted for an international organization) and the collection of published data, in focusing on important messages that should be given to the government, without an in-depth empirical and detailed research.Practical implications The paper is a kind of summary of a 80-page report to be published in the course of 2017. It is expected that the analysis will be clear enough to stimulate appropriate action by the Government of Rwanda.Social implications There is no direct social implications, but one may expect that the ideas if adopted by the government will help improving the living conditions in the country.Originality/value Such country reviews performed by international organizations are unique. They provide key insights on the innovation climate and policy of the nation that is studied, while they offer useful perspectives for countries at similar level of development. [ABSTRACT FROM AUTHOR]

Pesticides are an important and widely used tool for crop protection, but they also pose significant risks to agricultural sustainability, human health and the environment. In this paper, we examine whether mass media campaigns can help improve pesticide knowledge and change pesticide use behaviour among smallholder farmers in Rwanda and Uganda. We also assess the individual and combined effects of the campaign channels, which include interactive radio, plant health rallies, mobile SMS and video screenings. Applying a doubly robust method to survey data from 1327 maize-producing households across the two countries, we find that the mass media campaigns are significantly associated with improved farmer knowledge of pesticide risks and safety precautions. While the campaigns appear not to have discouraged the use of synthetic pesticides, they are significantly associated with increased adoption of safer alternatives to pesticides, including sustainable integrated pest management practices. The campaigns are also significantly correlated with increased use of protective equipment against pesticide exposure in both countries and reduced incidence of pesticide-related illnesses in Rwanda. We conclude that mass media campaigns (particularly using multiple complementary channels) can be effective in enhancing farmers' knowledge about pesticide risks and safety measures, and promote the adoption of safer pest management strategies. • The effects of mass media campaigns on pesticide use behaviour among farmers are studied. • Campaigns improve farmers' knowledge of pesticide risks and safety measures. • Campaigns boost the adoption of environmentally safer alternatives to synthetic pesticides. • Campaigns are associated with increased use of personal protective equipment items. • Effects are more pronounced for farmers exposed to multiple ICT channels. [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) has significant impacts on mental health. Community-focused interventions have shown promising results for addressing IPV in low-income countries, however, little is known about the implications of these interventions for women’s mental wellbeing. This paper analyses data from a community-focused policy intervention in Rwanda collected in 2013–14, including focus group discussions and in-depth interviews with community members (n = 59). Our findings point to three ways in which these community members responded to IPV: (1) reconciling couples experiencing violence, (2) engaging community support through raising cases of IPV during community discussions, (3) navigating resources for women experiencing IPV, including police, social services and legal support. These community responses support women experiencing violence by helping them access available resources and by engaging in community discussions. However, assistance is largely only offered to married women and responses tend to focus exclusively on physical rather than psychological or emotional forms of violence. Drawing on Campbell and Burgess’s (2012) framework for ‘community mental health competence’, we interrogate the potential implications of these responses for the mental wellbeing of women affected by violence. We conclude by drawing attention to the gendered nature of community responses to IPV and the potential impacts this may have for the mental health of women experiencing IPV. [ABSTRACT FROM AUTHOR]

This study examines how journalists in Rwanda, Uganda and Kenya perceive their journalistic role orientations in light of the countries' differing political systems, Rwanda representing the nation with the most restrictive political system, Uganda sitting in the middle and Kenya illustrating the nation that is home to the least restrictive political system. Data were analyzed from a comparative, quantitative online survey completed by 424 journalists from the three East African nations. Overall, the journalistic role orientations that emerged in each country align with the freedoms afforded by the political system in each country, revealing a trend that journalists in non-Western countries lean toward more interventionist roles (at times to the point of actively supporting their government), and journalists in countries with less restrictive political systems lean toward more adversarial roles (keeping their government in check). [ABSTRACT FROM AUTHOR]

In the past decade, many governments around the world have strayed neoliberal prescriptions to get closer to the East Asian governance model – the developmental state. Rwanda, which becomes a model for rapid socio-economic development in Africa, is considered as one of these states that take its inspiration from East Asia. Using an adapted theoretical framework and a rich dataset, we investigate whether the actions of the Rwandan state compare with the East Asian ideal-typical developmental state. Our analysis indicates that post-2000 Rwanda possesses two central features of the developmental state: a developmentally-oriented leadership and an efficient public administration that proved capable to implement its ambitious vision. We elaborate on the transformation of the development paradigm in Rwanda that goes beyond its ultra-market-friendly approach and its welcoming private sector environment. Our findings suggest that it is possible to reproduce the developmental state model today, leaving room for context-dependent adaptations. [ABSTRACT FROM AUTHOR]

Introduction Cancer is a major public health problem in Rwanda and other low- and middle-income countries (LMICs). While there have been some improvements in access to cancer treatment, the cost of care has increased, leading to financial toxicity and treatment barriers for many patients. This study explores the financial toxicity of cancer care in Rwanda. Methods This prospective cross-sectional study was conducted at 3 referral hospitals in Rwanda, which deliver most of the country's cancer care. Data were collected over 6 months from June 1 to December 1, 2022 by trained research assistants (RAs) using a modified validated data collection tool. RAs interviewed consecutive eligible patients with breast cancer, cervical cancer, colorectal cancer, Hodgkin's and non-Hodgkin's lymphoma who were on active systemic therapy. The study aimed to identify sources of financial burden. Data were analyzed using descriptive statistics. Results 239 patients were included; 75% (n  = 180/239) were female and mean age was 51 years. Breast, cervix, and colorectal cancers were the most common diagnoses (42%, 100/239; 24%, 58/239; and 24%, 57/239, respectively) and 54% (n  = 129/239) were diagnosed with advanced stage (stages III-IV). Financial burden was high; 44% (n  = 106/239) of respondents sold property, 29% (n  =  70/239) asked for charity from public, family, or friends, and 16% (n  = 37/239) took loans with interest to fund cancer treatment. Conclusion Despite health insurance which covers many elements of cancer care, a substantial proportion of patients on anti-cancer treatment in Rwanda experience major financial toxicity. Novel health financing solutions are needed to ensure accessible and affordable cancer care. [ABSTRACT FROM AUTHOR]

Foreign reporting plays a significant role in shining a light on stories of conflict and hardship that would potentially remain untold, but a reoccurring problem in this practice, particularly when the reportage is about non-Western countries, is the construction of otherness. In the case of Africa, Western reportage has perpetuated particular ideas about racial difference. According to Stuart Hall, this “racialized regime of representation” persisted into the late twentieth century, and while racial stereotypes have been and always are being contested, there is extensive evidence that points to a particular rhetoric when writing about Africa. Focusing on this issue of representation, as well as the role of the individual media practitioner in telling the stories of distant Others, this paper examines the extent to which a methodology involving deeper engagement may provide an effective strategy for subverting negative and dehumanising representations. Specifically, it examines a set of principles for the practice of slow journalism derived from an action research project carried out by the author in Rwanda from 2012 to 2014. The results demonstrate how by taking the time to engage and collaborate with local communities, a richer, more nuanced, and ultimately more culturally responsive form of journalism is possible. [ABSTRACT FROM PUBLISHER]

Twenty years after its horrific genocide, Rwanda has become a model for economic development. At the same time, its government has been criticised for authoritarian tactics and the use of violence. Missing from the often polarised debate are the connections between these two perspectives. Synthesising existing literature on Rwanda in light of a combined year of fieldwork, we argue that the Government of Rwanda is using the developmental infrastructure to deepen state power and expand political control. We first identify the historical pressures that have motivated the ruling Rwanda Patriotic Front (RPF) to reimagine the political landscape. Sectarian unrest, political rivalry, wider regional insecurity and aid withdrawal have all pressured the RPF to identify growth as strategic. However, the political transformation extends beyond a prioritisation of growth and encompasses the articulation of ideologies and new mindsets, the provision of social services and infrastructure and the reordering of the social and physical layout of the territory. Growth and social control go hand in hand. As such, this paper's main contribution is to bring together the two sides of the Rwandan debate and place the country in a broader sociological literature about the parallel development of capitalist relations and transformations in state power. [ABSTRACT FROM PUBLISHER]

Background: Because of the shortage of health professionals, particularly in specialty areas, Rwanda initiated the Human Resources for Health (HRH) Program. In this program, faculty from United States teaching institutions (USF) "twin" with Rwandan Faculty (RF) to transfer skills. This paper assesses the twinning model, exploring USF and RF goal setting, satisfaction and perceptions of the effectiveness of skill transfer within the twinning model.Methods: All USF and RF in the HRH Program from August 2012-May 2014 were invited to participate. An 85-item questionnaire for USF and 71-item questionnaire for RF were administered via Survey Monkey in April and May 2014. Associations among primary outcomes were assessed and factors related with outcomes were modeled using logistic regression.Results: Most RF and USF reported setting goals with their twin (89% and 71%, respectively). Half of RF (52%) reported effective skill transfer compared to 10% of USF. Only 38% of RF and 28% of USF reported being very satisfied with the twinning model. There was significant overlap in the three operational outcomes. For RF, the following factors were associated with outcomes: for effective skill transfer, being able to communicate in a common language and working at a nursing site outside of Kigali; and for satisfaction, 7+ years of professional experience and being part of a male RF-female USF twin pair. For USF, the following factors were associated with outcomes: for setting goals, prior teaching experience; and for satisfaction, experience in low resource settings for one month or less and feeling that HRH promotes a culture of respect.Conclusions: Twinning is the cornerstone of the HRH Program in Rwanda. These findings helped the HRH team identify key areas to improve the twinning experience including better recruitment and orientation of USF and RF, consideration of additional factors during the twinning process, provide language training support, facilitate joint twin activities and cross-cultural training and improve the site leadership buy-in and support of the program. These results can inform other programs using twinning to develop skills in the health workforce. [ABSTRACT FROM AUTHOR]

Background: Complications from premature birth contribute to 35% of neonatal deaths globally; therefore, efforts to improve clinical outcomes of preterm (PT) infants are imperative. Bubble continuous positive airway pressure (bCPAP) is a low-cost, effective way to improve the respiratory status of preterm and very low birth weight (VLBW) infants. However, bCPAP remains largely inaccessible in resource-limited settings, and information on the scale-up of this technology in rural health facilities is limited. This paper describes health providers' adherence to bCPAP protocols for PT/VLBW infants and clinical outcomes in rural Rwanda.Methods: This retrospective chart review included all newborns admitted to neonatal units in three rural hospitals in Rwanda between February 1st and October 31st, 2013. Analysis was restricted to PT/VLBW infants. bCPAP eligibility, identification of bCPAP eligibility and complications were assessed. Final outcome was assessed overall and by bCPAP initiation status.Results: There were 136 PT/VLBW infants. For the 135 whose bCPAP eligibility could be determined, 83 (61.5%) were bCPAP-eligible. Of bCPAP-eligible infants, 49 (59.0%) were correctly identified by health providers and 43 (51.8%) were correctly initiated on bCPAP. For the 52 infants who were not bCPAP-eligible, 45 (86.5%) were correctly identified as not bCPAP-eligible, and 46 (88.5%) did not receive bCPAP. Overall, 90 (66.2%) infants survived to discharge, 35 (25.7%) died, 3 (2.2%) were referred for tertiary care and 8 (5.9%) had unknown outcomes. Among the bCPAP eligible infants, the survival rates were 41.8% (18 of 43) for those in whom the procedure was initiated and 56.5% (13 of 23) for those in whom it was not initiated. No complications of bCPAP were reported.Conclusion: While the use of bCPAP in this rural setting appears feasible, correct identification of eligible newborns was a challenge. Mentorship and refresher trainings may improve guideline adherence, particularly given high rates of staff turnover. Future research should explore implementation challenges and assess the impact of bCPAP on long-term outcomes. [ABSTRACT FROM AUTHOR]

Current measures for monitoring progress towards universal health coverage (UHC) do not adequately account for populations that do not have the same level of access to quality care services and/or financial protection to cover health expenses for when care is accessed. This gap in accounting for unmet health care needs may contribute to underutilization of needed services or widening inequalities. Asking people whether or not their needs for health care have been met, as part of a household survey, is a pragmatic way of capturing this information. This analysis examined responses to self-reported questions about unmet need asked as part of 17 health, social and economic surveys conducted between 2001 and 2019, representing 83 low-, middle- and high-income countries. Noting the large variation in questions and response categories, the results point to low levels (less than 2%) of unmet need reported in adults aged 60+ years in countries like Andorra, Qatar, Republic of Korea, Slovenia, Thailand and Viet Nam to rates of over 50% in Georgia, Haiti, Morocco, Rwanda, and Zimbabwe. While unique, these estimates are likely underestimates, and do not begin to address issues of poor quality of care as a barrier or contributing to unmet need in those who were able to access care. Monitoring progress towards UHC will need to incorporate estimates of unmet need if we are to reach universality and reduce health inequalities in older populations. [ABSTRACT FROM AUTHOR]

The diversity of nematodes infecting amphibians is understudied in tropical Africa and unknown in Rwanda. Diversity assessment is hampered by the fact that species descriptions refer mostly to morphological features that are unlinked to DNA sequences of marker genes available in public databases. In this paper, we explore the abundance and diversity of parasitic nematodes in reed frogs Hyperolius kivuensis (n = 115), H. parallelus (n = 45) and H. viridiflavus (n = 100) collected in Rwanda. Five nematode species were identified morphologically as Orneoascaris chrysanthemoides, O. schoutedeni, Gendria leberrei, Aplectana chamaeleonis and Rhabdias collaris. Corresponding DNA sequences of 18S and COI genes were determined and subsequently deposited in GenBank. Aplectana chamaeleonis showed the highest prevalence (8.7%), but O. chrysanthemoides the highest mean intensity of infection (6.0) and largest number (24) of individuals in H. kivuensis. To the best of our knowledge, all amphibian hosts are new records for these nematode species, which are known to infect a wide range of amphibian and reptile species. Our findings suggest that nematode diversity is probably lower than previously assumed due to low host specificity. As morphological species identification is often challenging, our data facilitate molecular identification of adult and specifically larval nematodes found in amphibians of Sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Many African countries have encouraged the creation of local cooperatives in their efforts to legalize artisanal and small-scale mining. This exploratory case study of Rwanda's largest mining cooperative examines how cooperative business models, rather than direct company employment, might mitigate women's vulnerabilities in extractive industries. Through feminist political ecology's intersectionality framework, this research asks how cooperatives might improve women's outcomes along three lines—financial gains, gender violence reduction, and legal awareness and empowerment. Qualitative inquiry directly draws from semi-structured interviews, focus-group discussions, and participant observations, and indirectly from mapmaking workshops, with women who are full-time employees, seasonal miners, and farmers near six extraction sites. Based on content analysis in NVivo, this study finds the selected cooperative does not improve women's financial outcomes or lower violence rates compared to private companies in Rwanda. A specific form of gender violence, coerced transactional employment sex, is higher in the cooperative. However, cooperative work may expand women's rights conceptions and legal consciousness. Cooperative members demonstrated a greater understanding of supply chains, government functions, and conflict resolution pathways. These results indicate that cooperatives are not a panacea for rural women's marginalization but are a starting point for enhanced understandings of socio-economic and legal equities. [ABSTRACT FROM AUTHOR]

Eastern DRC is seriously affected by a protracted warfare involving illicit exploitation of natural resources, corruption, humanitarian crisis and terrorism carried out by armed groups including the Allied Democratic Forces (ADF) and the Movement of 23 March (M23). According to DRC government, M23 is a terrorist group supported by Rwanda Defence Forces (RDF). Invasion and terrorism drive the war and the chaos. For Rwanda, fighting and chaos derive from ethnic conflicts over land, citizenship, local political power, and state failures. To many observers, ongoing violence and fighting are driven by rent seeking by Congolese military commanders, lack of State authority, distorted rule of law at both national and local levels, the abuse of public office for private gain (corruption), failed defence/security and justice sector reforms, undisciplined civilian armed and unarmed combatants, warlords and opportunist warmongers. Overall, state failures combined with globalized war diseconomy as conducted by multinational companies, failed multiparty system regarding democratic governance system drive ongoing chaos and armed violence, beyond government control and defence capabilities, despite peace agreements and the involvement of international and regional peace peacekeeping initiatives. Our analysis suggests that the war strategy being used resembles to what McKew refers to as the Gerasimov Doctrine, a chaos theory of political warfare which is used by Russia in Ukraine war. [ABSTRACT FROM AUTHOR]

Peste des petits ruminants (PPR), a contagious viral disease affecting small ruminants, has been targeted by the global community for eradication within the next 10 years. However, eradication will require substantial money, human resources, coordination among actors, and individual commitments. The objective was to estimate the cost of PPR at a household level, thereby providing information on the potential economic benefits of PPR eradication and the incentives for small ruminant keepers to actively participate in the PPR Global Eradication Programme. This study focused on four sub‐Saharan countries: Ethiopia, Malawi, Mali and Rwanda. Publicly available household level data assembled by FAO were used. A bioeconomic model was built to estimate impacts of PPR for a standardized theoretical area, where each household raised an average small ruminant herd or flock. Model outputs were used to estimate, at a household level, income loss due to a PPR outbreak. We constructed various income scenarios to account for the variability of small ruminant income as a proportion of total household annual income. Household income losses ranged from 2% to 40% of total annual income; percentages varied depending on the income scenario and on the gross annual economic impact of PPR on small ruminant production, which ranged from 20% to 80%, based on results of the bioeconomic model. As expected, the more small ruminant production contributed to household income the greater the impact. Estimates provided herein warn decision makers that, given the heterogeneous impact of PPR on household income, the willingness of small ruminant decision makers to participate in the PPR Global Eradication Programme may vary widely and tailored approaches should be devised and implemented. [ABSTRACT FROM AUTHOR]

The degradation of soil, vegetation and socio-economic transformations are a huge threat to Africa's land production. This study aimed to (i) assess the soil and land productivity of standing biomass and (ii) determine the effect of rainfall on the standing biomass in Eastern Africa. Soil productivity was determined using the Soil Productivity Index (SPI) and a simplified model was developed to estimate the Net Primary Productivity (NPP). The SPI indicators used included soil-organic matter, texture, soil moisture, base-saturation, pH, cation-exchange-capacity, soil-depth and drainage. The inputs of the simplified model are: MODIS Soil Adjusted Vegetation Index (SAVI), soil erosion, soil nutrient content and input, rainfall, land-use/cover and agro-ecological zones. The findings reveal that the countries with the most productive soils are Mauritius, Rwanda and South Sudan—while, for standing biomass, the countries with the highest spatial extent are Mauritius (97%), Rwanda (96%), Uganda (95%), South Sudan (89%), Ethiopia (47%) and Kenya (36%). Standing biomass is dominant in biomes such as natural forests, woodlands, croplands, grasslands, wetlands and tree-plantations. High land productivity was attributed to soil quality and management, land policy reforms, favourable climatic conditions and sustainable land husbandry activities. Rainfall was significantly correlated with standing biomass in most of the studied countries (p < 0.05) except Djibouti and Rwanda. Therefore, monitoring soil health, use and land reforms are key to sustaining vegetative biomass. [ABSTRACT FROM AUTHOR]

• Rwanda's government implemented a zoning policy in its coffee industry. • Mixed methods are used to analyze how zoning affected buyer-farmer relationships. • Buyers were more likely to give farmers bonuses where zoning was well-implemented. • We do not find evidence that zoning increased coffee farmer investment. • Buyers believed that zoning improved their relationships with farmers. Contract farming has the potential to both connect farmers to global markets and limit farmers' sale channel choices. In countries where contract enforcement is weak, some governments have enforced monopsony zoning systems in which farmers within a zone must sell to a specific buyer. There is variance in zoning systems' effectiveness in improving relationships between suppliers and buyers. In 2016, Rwanda implemented a zoning system aimed at reducing side-selling by coffee farmers and improving service provision to farmers by coffee mills. This paper analyzes the impacts of zoning on contracting between farmers and mills. We use data from farmer surveys from before and after the shift to zoning to estimate a difference-in-differences model analyzing the effects of zoning on second payments (i.e., bonuses) paid to farmers out of mill profits. We use the share of farmers aware of zoning at the local level as a proxy for the relative strength of zoning implementation and analyze the effect of zoning on farmers being promised or receiving second payments by coffee mills. We find that an increase in the degree of zoning implementation (proxied by the proportion of local coffee farmers that know about zoning) is associated with an increase in the probability that a farmer is promised or receives a second payment. Consistent with quantitative findings, interviews with mill managers suggest that zoning motivated mills to improve service provision. We do not find evidence that zoning increased farmer investment in their coffee plantations in the short run. However, qualitative evidence suggests that zoning reduced local trader activity and farmer side-selling, which benefited mills. [ABSTRACT FROM AUTHOR]

Objectives: Effective coverage of non-communicable disease (NCD) care in sub-Saharan Africa remains low, with the majority of services still largely restricted to central referral centres. Between 2015 and 2017, the Rwandan Ministry of Health implemented a strategy to decentralise outpatient care for severe chronic NCDs, including type 1 diabetes, heart failure and severe hypertension, to rural first-level hospitals. This study describes the facility-level implementation outcomes of this strategy.Methods: In 2014, the Ministry of Health trained two nurses in each of the country's 42 first-level hospitals to implement and deliver nurse-led, integrated, outpatient NCD clinics, which focused on severe NCDs. Post-intervention evaluation occurred via repeated cross-sectional surveys, informal interviews and routinely collected clinical data over two rounds of visits in 2015 and 2017. Implementation outcomes included fidelity, feasibility and penetration.Results: By 2017, all NCD clinics were staffed by at least one NCD-trained nurse. Among the approximately 27 000 nationally enrolled patients, hypertension was the most common diagnosis (70%), followed by type 2 diabetes (19%), chronic respiratory disease (5%), type 1 diabetes (4%) and heart failure (2%). With the exception of warfarin and beta-blockers, national essential medicines were available at more than 70% of facilities. Clinicians adhered to clinical protocols at approximately 70% agreement with evaluators.Conclusion: The government of Rwanda was able to scale a nurse-led outpatient NCD programme to all first-level hospitals with good fidelity, feasibility and penetration as to expand access to care for severe NCDs. [ABSTRACT FROM AUTHOR]

Objective: Road traffic crashes (RTCs) are common among motorcyclists in Kigali, Rwanda. The Service d'Aide Medicale Urgente (SAMU), a prehospital ambulance service, responds to many of these crashes. We aimed to describe motorcycle-related RTCs managed by SAMU.Methods: SAMU clinical data including demographic information, injury characteristics, and management details were analyzed descriptively for all motorcycle crashes occurring between December 2012 and July 2016.Results: Every patient included in this study was injured. These patients all called the ambulance for their injuries after a motorcycle crash. There were 2,912 motorcycle-related RTCs over the study period, representing 26% of all patients managed by SAMU. The incidence of motorcycle crashes in Kigali was 258 crashes per 100,000 people over the 3.5-year study period. The average age was 30 years and 80% were males. The most common injuries were to the lower extremities (n = 958, 33%), head (n = 878, 30%), or upper extremities (n = 453, 16%). Injuries often resulted in fractures of extremities (n = 740, 25%) and external hemorrhage anywhere in the body (unspecified region; n = 660, 23%), yet few were severe based on the Kampala Trauma Score (n = 23, 2%) and Glasgow Coma Scale (n = 42, 1.5%). The most common interventions were provision of diclofenac (n = 1,526, 52.5%), peripheral intravenous (IV) access (n = 1,217, 42%), and administration of IV fluids (n = 1,048, 36%).Conclusion: Motorcycle-related RTCs represent a large burden of disease for patients treated by SAMU in Kigali, Rwanda. Young men are most at risk of injury, which imposes a financial strain on society. Though injuries occurred frequently, critical trauma cases from motorcycle crashes were uncommon. This may be a result of several initiatives in Rwanda to improve road safety. [ABSTRACT FROM AUTHOR]

Two new Bloszykiella species are discovered and described from the Afrotropical realm. Bloszykiella rammsteinisp. nov. (from Zimbabwe) differs from its congeners in the sculptural pattern of the dorsal shield, the strongly sclerotized U-shaped grooves on the dorsal shield and pilose dorsal setae. Bloszykiella lindemannisp. nov. (from Rwanda) differs from the other species in the shape of the sternal setae, setae on the apical margin of the pygidial shield and the sculptural pattern of the female genital shield. [ABSTRACT FROM AUTHOR]

This study evaluated the poverty reduction impact of the adoption of cropping system intensification (CSI) technologies using the endogenous switching regression (ESR) model in the Great Lakes region of Africa that comprises Burundi, eastern DR Congo, and Rwanda. The study data came from a household survey of 1,495 sample households interviewed between October and December 2014. Results indicated that the adoption of the CSI technologies had increased crop yield, crop income, and per capita consumption expenditure in the region, resulting in poverty reduction. Among the three countries, eastern DR Congo witnessed the highest poverty reduction (13% points) followed by Rwanda (6% points) and Burundi (2% points). Considering the adoption rate and size of the target population in each country at baseline, an estimated 180 thousand poor individuals had escaped poverty due to the adoption of the CSI technologies. This presents important evidence in favor of promoting CSI technologies as part of poverty reduction strategy. Given the large population size that remains poor even after adoption, we suggest that research‐based poverty reduction strategies such as the CSI technologies should be complemented with development interventions. [ABSTRACT FROM AUTHOR]

Introduction: Couples' voluntary HIV counselling and testing (CVCT) is a high‐impact HIV prevention intervention in Rwanda and Zambia. Our objective was to model the cost‐per‐HIV infection averted by CVCT in six African countries guided by an HIV prevention cascade framework. The HIV prevention cascade as yet to be applied to evaluating CVCT effectiveness or cost‐effectiveness. Methods: We defined a priority population for CVCT in Africa as heterosexual adults in stable couples. Based on our previous experience nationalizing CVCT in Rwanda and scaling‐up CVCT in 73 clinics in Zambia, we estimated HIV prevention cascade domains of motivation for use, access and effectiveness of CVCT as model parameters. Costs‐per‐couple tested were also estimated based on our previous studies. We used these parameters as well as country‐specific inputs to model the impact of CVCT over a five‐year time horizon in a previously developed and tested deterministic compartmental model. We consider six countries across Africa with varied HIV epidemics (South Africa, Zimbabwe, Kenya, Tanzania, Ivory Coast and Sierra Leone). Outcomes of interest were the proportion of HIV infections averted by CVCT, nationwide CVCT implementation costs and costs‐per‐HIV infection averted by CVCT. We applied 3%/year discounting to costs and outcomes. Univariate and Monte Carlo multivariate sensitivity analyses were conducted. Results: We estimated that CVCT could avert between 54% (Sierra Leone) and 62% (South Africa) of adult HIV infections. Average costs‐per‐HIV infection averted were lowest in Zimbabwe ($550) and highest in South Africa ($1272). Nationwide implementations would cost between 7% (Kenya) and 21% (Ivory Coast) of a country's President's Emergency Plan for AIDS Relief (PEPFAR) budget over five years. In sensitivity analyses, model outputs were most sensitive to estimates of cost‐per‐couple tested; the proportion of adults in heterosexual couples and HIV prevention cascade domains of CVCT motivation and access. Conclusions: Our model indicates that nationalized CVCT could prevent over half of adult HIV infections for 7% to 21% of the modelled countries' five‐year PEPFAR budgets. While other studies have indicated that CVCT motivation is high given locally relevant promotional and educational efforts, without required indicators, targets and dedicated budgets, access remains low. [ABSTRACT FROM AUTHOR]

Background: One of the reported causes of high malnutrition rates in Burundi and Rwanda is children's inadequate dietary habits. The diet of children may be affected by individual characteristics and by the characteristics of the households and the communities in which they live. We used the minimum dietary diversity of children (MDD-C) indicator as a proxy of diet quality aiming at: 1) assess how much of the observed variation in MDD-C was attributed to community clustering, and 2) to identify the MDD-C associated factors. Methods: Data was obtained from the 2010 Demographic and Health Surveys of Burundi and Rwanda, from which only children 6 to 23 months from rural areas were analysed. The MDD-C was calculated according to the 2007 WHO/UNICEF guidelines. We computed the intra-class coefficient to assess the percentage of variation attributed to the clustering effect of living in the same community. And then we applied two-level logit regressions to investigate the association between MDD-C and potential risk factors following the hierarchical survey structure of DHS. Results: The MDD-C was 23% in rural Rwanda and 16% in rural Burundi, and a 29% of its variation in Rwanda and 17% in Burundi was attributable to community clustering. Increasing age and living standards were associated with higher MDD-C in both countries, and only in Burundi also increasing level of education of the mother's partner. In Rwanda alone, the increasing ages of the head of the household and of the mother at first birth were also positively associated with it. Despite the identification of an important proportion of the MDD-C variation due to clustering, we couldn't identify any community variable significantly associated with it. Conclusions: We recommend further research using hierarchical models, and to integrate dietary diversity in holistic interventions which take into account both the household's and the community's characteristics the children live in. [ABSTRACT FROM AUTHOR]

Introduction: Use of tobacco and its products are the single most preventable cause of death in the world. The objective of this study was to determine the prevalence of current tobacco use and identify associated factors among Rwandans aged 15–34 years. Methods: This study involved secondary analysis of existing data from the nationally representative WHO STEPwise approach to Surveillance of non-communicable diseases (STEPS) conducted in 2013 to explore the prevalence of tobacco use and its associated factors in Rwanda. Data of 3,900 youth participants (15–34 years old) who had been selected using multistage cluster sampling during the survey was analyzed. The prevalence of current smoking along with socio-demographic characteristics of the sample were determined and multivariable logistic regression was employed to identify independent factors associated with current tobacco use. Results: The prevalence (weighted) of current tobacco use (all forms) was 8% (95%CI: 7.08–9.01). The prevalence was found to be significantly higher among males, young adults aged 24–34, youth with primary school education or less, those from Southern province, people with income (work in public, private organizations and self-employed) and young married adults. However, geographical location i.e. urban (7%) and rural (8%) settings did not affect prevalence of tobacco use. Factors that were found to be associated with current tobacco use through the multivariate analysis included being male, aged 25 years and above, having an income, and residing in Eastern, Kigali City and Southern Province compared to Western province. Conclusion: The association between smoking and socio-demographic characteristics among Rwandan youth identified in this study provides an opportunity for policy makers to tailor future tobacco control policies, and implement coordinated, high-impact interventions to prevent initiation of tobacco use among the youth. [ABSTRACT FROM AUTHOR]

Background: Schistosomiasis is a neglected tropical disease caused by Schistosoma parasites. Intervention relies on identifying high-risk regions, yet rapid Schistosoma diagnostics (Kato-Katz stool assays (KK) and circulating cathodic antigen urine assays (CCA)) yield different prevalence estimates. We mapped S. mansoni prevalence and delineated at-risk regions using a survey of schoolchildren in Rwanda, where Schistosoma mansoni is an endemic parasite. We asked if different diagnostics resulted in disparities in projected infection risk. Methods: Infection data was obtained from a 2014 Rwandan school-based survey that used KK and CCA diagnostics. Across 386 schools screened by CCA (N = 19,217). To allow for uncertainty when interpreting ambiguous CCA trace readings, which accounted for 28.8% of total test results, we generated two presence-absence datasets: CCA trace as positive and CCA trace as negative. Samples (N = 9,175) from 185 schools were also screened by KK. We included land surface temperature (LST) and the Normalized Difference Vegetation and Normalized Difference Water Indices (NDVI, NDWI) as predictors in geostatistical regressions. Findings: Across 8,647 children tested by both methods, prevalence was 35.93% for CCA trace as positive, 7.21% for CCA trace as negative and 1.95% for KK. LST was identified as a risk factor using KK, whereas NDVI was a risk factor for CCA models. Models predicted high endemicity in Northern and Western regions of Rwanda, though the CCA trace as positive model identified additional high-risk areas that were overlooked by the other methods. Estimates of current burden for children at highest risk (boys aged 5–9 years) varied by an order of magnitude, with 671,856 boys projected to be infected by CCA trace as positive and only 60,453 projected by CCA trace as negative results. Conclusions: Our findings show that people in Rwanda’s Northern, Western and capital regions are at high risk of S. mansoni infection. However, variation in identification of environmental risk factors and delineation of at-risk regions using different diagnostics likely provides confusing messages to disease intervention managers. Further research and statistical analyses, such as latent class analysis, can be used to improve CCA result classification and assess its use in guiding treatment regimes. [ABSTRACT FROM AUTHOR]

News media played a prominent role in perpetuating the 1994 Rwandan genocide. Since then, Rwanda has undergone impressive social and economic growth, but the media landscape during this redevelopment remains understudied. Qualitative interviews with Rwandan journalists reveal that reporters censor themselves to promote peace and reunification. Short-term, prioritizing social good over media rights might help unify the country, but ultimately it could limit development and reinforce existing authoritarian power structures. Findings suggest that McQuail's development media theory and Hachten's developmental concept maintain relevance but point to the need for a new or revised media development paradigm. [ABSTRACT FROM AUTHOR]

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended. [ABSTRACT FROM AUTHOR]

This article focuses on the postcolonial economies of Cameroon and Rwanda, two former colonies whose political economies have quintessentially come to define the present character, and nature, of the African state. The social and economic challenges they have faced as sovereign states present serious questions—for both Africans and people worldwide—regarding economic and political development. Are the economies of these states dependent on or independent of their colonial economic heritages? In this regard, are they state-run economies or free-market/mixed-market economies? If they are either of the two types, what has this meant for the states themselves, and how have their political regimes—whether created or inherited—implemented a free-market/mixed-market economy or responded to these economic realities? Through a comparative analysis, utilising primary and secondary sources and data sets, this article argues that the political evolution within these states, and the historical circumstances within which their economies came into being, created economies that have had paradoxical effects. Ultimately, it is argued that historical circumstance, populist politics, and international financial capitalism created neo-colonial economic realities within which Cameroon and Rwanda continue to develop. [ABSTRACT FROM AUTHOR]

Background: Despite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In sub-Saharan Africa (SSA), the Millennium Development Goals (MDGs) for child mortality were met only by a few countries. Valid concerns exist as to whether the region would meet new Sustainable Development Goals (SDGs) for under-5 mortality. We therefore examine further sources of variation by assessing age patterns, trends, and forecasts of mortality rates.Methods and Findings: Data came from 106 nationally representative Demographic and Health Surveys (DHSs) with full birth histories from 31 SSA countries from 1990 to 2017 (a total of 524 country-years of data). We assessed the distribution of age at death through the following new demographic analyses. First, we used a direct method and full birth histories to estimate under-5 mortality rates (U5MRs) on a monthly basis. Second, we smoothed raw estimates of death rates by age and time by using a two-dimensional P-Spline approach. Third, a variant of the Lee-Carter (LC) model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) to adjust, validate, and minimize the risk of bias in survival, truncation, and recall in mortality estimation. Our mortality model revealed substantive declines of death rates at every age in most countries but with notable differences in the age patterns over time. U5MRs declined from 3.3% (annual rate of reduction [ARR] 0.1%) in Lesotho to 76.4% (ARR 5.2%) in Malawi, and the pace of decline was faster on average (ARR 3.2%) than that observed for infant (IMRs) (ARR 2.7%) and neonatal (NMRs) (ARR 2.0%) mortality rates. We predict that 5 countries (Kenya, Rwanda, Senegal, Tanzania, and Uganda) are on track to achieve the under-5 sustainable development target by 2030 (25 deaths per 1,000 live births), but only Rwanda and Tanzania would meet both the neonatal (12 deaths per 1,000 live births) and under-5 targets simultaneously. Our predicted NMRs and U5MRs were in line with those estimated by the UN IGME by 2030 and 2050 (they overlapped in 27/31 countries for NMRs and 22 for U5MRs) and by the Institute for Health Metrics and Evaluation (IHME) by 2030 (26/31 and 23/31, respectively). This study has a number of limitations, including poor data quality issues that reflected bias in the report of births and deaths, preventing reliable estimates and predictions from a few countries.Conclusions: To our knowledge, this study is the first to combine full birth histories and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in SSA. We demonstrate that countries with a rapid pace of mortality reduction (ARR ≥ 3.2%) across ages would be more likely to achieve the SDG mortality targets. However, the lower pace of neonatal mortality reduction would prevent most countries from achieving those targets: 2 countries would reach them by 2030, 13 between 2030 and 2050, and 13 after 2050. [ABSTRACT FROM AUTHOR]

We study how armed violence affected educational outcomes in Rwanda during the nineties, relying on two waves of population census data and on a difference-in-differences identification strategy. Results indicate that the violence caused a drop of about 1 year of education for the individuals exposed to the violence at schooling age. The drop was slightly larger for girls than for boys. While increased dropouts and school delays explain the drop in primary schooling, secondary schooling was mainly affected by a drop in enrolments. Finally, in a within-country analysis, we find no robust link between subnational variations in the drop in schooling and the intensity of the 1994 genocide – the most intense conflict event that took place in the country over the studied period. We present possible explanations for the observed patterns and provide related policy implications. [ABSTRACT FROM AUTHOR]

Background: The environmental and health impacts of reliance on solid fuels and traditional cookstoves in low-income countries have motivated the promotion of household cooking energy systems that use cleaner burning fuels and cookstoves that lead to reduced exposure to harmful pollutants. Little is known about adoption and use of such systems from the users’ perspective. Methods: We explored the facilitators and barriers to adoption and use of a private sector marketed household cooking energy system that uses sustainably produced biomass pellets and the cleanest burning fan micro-gasification stove currently available. We conducted 48 in-depth qualitative interviews in Gisenyi, Rwanda with decision-makers and cooks in 16 households that adopted the improved cookstove system and 8 non-adopter households. Results: Reported facilitators and barriers to adoption and non-adoption, as well as use and non-use were complex, and in some cases, contradictory. Some adopters noted that cleanliness and low smoke production were major facilitators to adoption and use, while other adopters and non-adopters said the cookstoves blackened and damaged cooking pots and produced excessive smoke. Our findings suggest that correct use of the stove mediates user experience. Cost was likewise reported as a facilitator among some adopters and a barrier among other adopters and non-adopters. Peer influence played a significant role as both a barrier and a facilitator to adoption and transcended other factors. Positive peer influence describing the cleanliness, affordability, and efficiency of the cookstove system encouraged adoption and use, while negative comments by peers regarding excessive smoke and damaged cooking pots discouraged adoption. Commentaries by some participants suggest that inadequate training and instruction may be primary causes of the discrepancies. Conclusion: Cost, cleanliness, communication among peer networks, and adequate training and instruction are important factors associated with the adoption and use of improved cookstoves and should be prioritized in the implementation of improved cookstove programs. [ABSTRACT FROM AUTHOR]

Background: Contraceptive vaginal rings could play a role in expanding the contraceptive method mix and in preparing communities for the introduction of HIV prevention and multipurpose rings. Methods: We conducted an open label single-centre randomised clinical trial of intermittent versus continuous use of NuvaRing® in Kigali, Rwanda, in 2013–2014. We randomised 120 HIV-negative women 1:1 to intermittent use (three rings with a ring-free week in between rings) or continuous use (four rings without ring-free weeks). Women underwent an interview, counselling, and a speculum examination, and were tested for pregnancy, bacterial vaginosis (BV) by Nugent scoring, yeasts and trichomonads on wet mount, and sexually transmitted infections. Findings: Only one woman withdrew early. Deliberate ring removals were rare, but spontaneous ring expulsions occurred during 14% of ring use periods. There were no incident pregnancies, serious adverse events, serious social harms, or early discontinuations for safety reasons. Systemic side effects were uncommon, and local side effects were not significantly differently distributed between groups except for lower abdominal pain (P = 0.013). The incidence of vaginal yeasts during ring use was high: 22% of intermittent users and 27% of continuous users had incident vaginal yeasts at one or multiple ring removal visits (P = 0.666), and symptomatic vaginal yeast cases were more common in the continuous than intermittent users (P = 0.031). In contrast, mean Nugent scores improved over time in both groups. Conclusions: Intermittent and continuous NuvaRing® use were safe in Rwandan women and improved Nugent scores over time. However, attention should be paid to ring expulsions and to a potential increased risk of vaginal candidiasis. [ABSTRACT FROM AUTHOR]

This scoping study assessed the realization of the rights for persons with disabilities in Rwanda since the signing of the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD) in 2008. Underpinned by the five-stage framework of Arksey and O’Malley, the scoping study examined peer-reviewed literature published between 2008 and 2017. Nine electronic databases were searched using keywords specific to disability in Rwanda. Data were charted by three reviewers according to pre-determined and emergent categories. Descriptive statistics were used to describe the data sources. A total of 60 scholarly articles met the inclusion criteria. Within the research, studies pertaining to the UN CRPD Articles of health, awareness raising, accessibility, and children with disabilities were the most published. The literature identified a movement towards the realization of the rights for persons with disabilities in Rwanda since the country signed the UN CRPD. Despite efforts to meet these rights, discrimination against persons with disabilities still exists and greater investment in the disability sector is needed, particularly for justice, social protection, and mental health services. Given the state of the evidence, concerning research gaps also exist in regards to deinstitutionalization and protection issues (i.e., violence and abuse). This consolidation of evidence may help to inform the decision-making priorities for government and civil society organizations in policy and programming and also direct future research. [ABSTRACT FROM AUTHOR]

Background: Universal access to Primary Eye Care (PEC) is a key global initiative to reduce and prevent avoidable causes of visual impairment (VI). PEC can address minor eye conditions, simple forms of uncorrected refractive error (URE) and create a referral pathway for specialist eye care, thus offering a potential solution to a lack of eye health specialists in low-income countries. However, there is little information on the population need for PEC, including prevalence of URE in all ages in Sub-Saharan Africa. Methods: A national survey was conducted of people aged 7 and over in Rwanda in September-December 2016. Participants were selected through two-stage probability proportional to size sampling and compact segment sampling. VI (visual acuity<6/12) was assessed using Portable Eye Examination Kit (PEEK); URE was detected using a pinhole and presbyopia using local near vision test. We also used validated questionnaires to collect socio-demographic and minor eye symptoms information. Prevalence estimates for VI, URE and need for PEC (URE, presbyopia with good distance vision, need for referrals and minor eye conditions) were age and sex standardized to the Rwandan population. Associations between age, sex, socio-economic status and the key outcomes were examined using logistic regression. Results: 4618 participants were examined and interviewed out of 5361 enumerated (86% response rate). The adjusted population prevalence of VI was 3.7% (95%CI = 3.0–4.5%), URE was 2.2% (95%CI = 1.7–2.8%) and overall need for PEC was 34.0% (95%CI = 31.8–36.4%). Women and older people were more likely to need PEC and require a referral. Conclusions: Nearly a third of the population in Rwanda has the potential to benefit from PEC, with greater need identified in older people and women. Universal access to PEC can address unmet eye health needs and public health planning needs to ensure equitable access to older people and women. [ABSTRACT FROM AUTHOR]

Background: Integrated management of childhood illness (IMCI) can reduce under-5 morbidity and mortality in low-income settings. A program to strengthen IMCI practices through Mentorship and Enhanced Supervision at Health centers (MESH) was implemented in two rural districts in eastern Rwanda in 2010. Methods: We estimated cost per improvement in quality of care as measured by the difference in correct diagnosis and correct treatment at baseline and 12 months of MESH. Costs of developing and implementing MESH were estimated in 2011 United States Dollars (USD) from the provider perspective using both top-down and bottom-up approaches, from programmatic financial records and site-level data. Improvement in quality of care attributed to MESH was measured through case management observations (n = 292 cases at baseline, 413 cases at 12 months), with outcomes from the intervention already published. Sensitivity analyses were conducted to assess uncertainty under different assumptions of quality of care and patient volume. Results: The total annual cost of MESH was US$ 27,955.74 and the average cost added by MESH per IMCI patient was US$1.06. Salary and benefits accounted for the majority of total annual costs (US$22,400 /year). Improvements in quality of care after 12 months of MESH implementation cost US$2.95 per additional child correctly diagnosed and $5.30 per additional child correctly treated. Conclusions: The incremental costs per additional child correctly diagnosed and child correctly treated suggest that MESH could be an affordable method for improving IMCI quality of care elsewhere in Rwanda and similar settings. Integrating MESH into existing supervision systems would further reduce costs, increasing potential for spread. [ABSTRACT FROM AUTHOR]

Background: Nearly a quarter of a million children have acquired HIV, prompting the implementation of new protocols—Option B and B+—for treating HIV+ pregnant women. While efficacy has been demonstrated in randomized trials, there is limited real-world evidence on the impact of these changes. Using longitudinal, routinely collected data we assessed the impact of the adoption of WHO Option B in Rwanda on mother to infant transmission. Methods: We used interrupted time series analysis to evaluate the impact of Option B on mother-to-child HIV transmission in Rwanda. Our primary outcome was the proportion of HIV tests in infants with positive results at six weeks of age. We included data for 20 months before and 22 months after the 2010 policy change. Results: Of the 15,830 HIV tests conducted during our study period, 392 tested positive. We found a significant decrease in both the level (-2.08 positive tests per 100 tests conducted, 95% CI: -2.71 to -1.45, p < 0.001) and trend (-0.11 positive tests per 100 tests conducted per month, 95% CI: -0.16 to -0.07, p < 0.001) of test positivity. This represents an estimated 297 fewer children born without HIV in the post-policy period or a 46% reduction in HIV transmission from mother to child. Conclusions: The adoption of Option B in Rwanda contributed to an immediate decrease in the rate of HIV transmission from mother to child. This suggests other countries may benefit from adopting these WHO guidelines. [ABSTRACT FROM AUTHOR]

Background: It is increasingly apparent that access to healthcare without adequate quality of care is insufficient to improve population health outcomes. We assess whether the most commonly measured attribute of health facilities in low- and middle-income countries (LMICs)-the structural inputs to care-predicts the clinical quality of care provided to patients.Methods and Findings: Service Provision Assessments are nationally representative health facility surveys conducted by the Demographic and Health Survey Program with support from the US Agency for International Development. These surveys assess health system capacity in LMICs. We drew data from assessments conducted in 8 countries between 2007 and 2015: Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania, and Uganda. The surveys included an audit of facility infrastructure and direct observation of family planning, antenatal care (ANC), sick-child care, and (in 2 countries) labor and delivery. To measure structural inputs, we constructed indices that measured World Health Organization-recommended amenities, equipment, and medications in each service. For clinical quality, we used data from direct observations of care to calculate providers' adherence to evidence-based care guidelines. We assessed the correlation between these metrics and used spline models to test for the presence of a minimum input threshold associated with good clinical quality. Inclusion criteria were met by 32,531 observations of care in 4,354 facilities. Facilities demonstrated moderate levels of infrastructure, ranging from 0.63 of 1 in sick-child care to 0.75 of 1 for family planning on average. Adherence to evidence-based guidelines was low, with an average of 37% adherence in sick-child care, 46% in family planning, 60% in labor and delivery, and 61% in ANC. Correlation between infrastructure and evidence-based care was low (median 0.20, range from -0.03 for family planning in Senegal to 0.40 for ANC in Tanzania). Facilities with similar infrastructure scores delivered care of widely varying quality in each service. We did not detect a minimum level of infrastructure that was reliably associated with higher quality of care delivered in any service. These findings rely on cross-sectional data, preventing assessment of relationships between structural inputs and clinical quality over time; measurement error may attenuate the estimated associations.Conclusion: Inputs to care are poorly correlated with provision of evidence-based care in these 4 clinical services. Healthcare workers in well-equipped facilities often provided poor care and vice versa. While it is important to have strong infrastructure, it should not be used as a measure of quality. Insight into health system quality requires measurement of processes and outcomes of care. [ABSTRACT FROM AUTHOR]

Background: Management of emergency general surgical conditions remains a challenge in rural sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study describes the burden of emergency general surgical conditions and the ability to provide care for these conditions at three rural district hospitals in Rwanda.Methods: This retrospective cross-sectional study included all patients presenting to Butaro, Kirehe and Rwinkwavu District Hospitals between January 1st 2015 and December 31st 2015 with emergency general surgical conditions, defined as non-traumatic, non-obstetric acute care surgical conditions. We describe patient demographics, clinical characteristics, management and outcomes.Results: In 2015, 356 patients presented with emergency general surgical conditions. The majority were male (57.2%) and adults aged 15-60 years (54.5%). The most common diagnostic group was soft tissue infections (71.6%), followed by acute abdominal conditions (14.3%). The median length of symptoms prior to diagnosis differed significantly by diagnosis type (p < 0.001), with the shortest being urological emergencies at 1.5 days (interquartile range (IQR):1, 6) and the longest being complicated hernia at 17.5 days (IQR: 1, 208). Of all patients, 54% were operated on at the district hospital, either by a general surgeon or general practitioner. Patients were more likely to receive surgery if they presented to a hospital with a general surgeon compared to a hospital with only general practitioners (75% vs 43%, p < 0.001). In addition, the general surgeon was more likely to treat patients with complex diagnoses such as acute abdominal conditions (33.3% vs 4.1%, p < 0.001) compared to general practitioners. For patients who received surgery, 73.3% had no postoperative complications and 3.2% died.Conclusion: While acute abdominal conditions are often considered the most common emergency general surgical condition in sub-Saharan Africa, soft tissue infections were the most common in our setting. This could represent a true difference in epidemiology in rural settings compared to referral facilities in urban settings. Patients were more likely to receive an operation in a hospital with a general surgeon as opposed to a general practitioner. This provides evidence to support increasing the surgical workforce in district hospitals in order to increase surgical availability for patients. [ABSTRACT FROM AUTHOR]

The natural history and mortality of type 1 diabetes in adolescents in Africa is not well characterized. Our aim is, therefore, to describe these characteristics for cases in the Rwanda Life For a Child (LFAC) program. Participants (≤25 years old) were the first 500 children and youth enrolled in the Rwanda LFAC program from 2004 to 2012. Clinical and demographic data were extracted from LFAC forms, and vital status was evaluated as of November 1, 2011. For the first 500 participants, 5-year survival was 93.8% while crude mortality was 13.9/1000 (95% CI 9.0-20.6/1000) person years of diabetes. However, since vital status is unknown for 134 participants, mortality could be as high as 40.2/1000 person years of diabetes if all missing cases died. Mortality was directly associated with age at diagnosis, and inversely to calendar year of first visit, BMI, and monitoring frequency. Hypertension prevalence reached 46% by 2012. Mortality rates associated with type 1 diabetes in Rwanda are similar to those in other African countries, but higher than rates in developed countries. Delayed diagnosis may contribute to excess mortality risk, but recent improvements in survival suggest that advancements are being made. Hypertension and loss to follow-up need to be addressed. [ABSTRACT FROM AUTHOR]