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Rwanda and Nicaragua are well-known for their high levels of gender equality despite being developing authoritarian regime countries, especially when the gender equality is measured using official norms such as institution and law. However, when considering unofficial social norms such as traditional customs, cultural practices, and violence against women, women’s everyday lives are not as good as the official norms suggest. In the SIGI Index, which includes attitudes and practices as indicators, these two countries rank much lower (160th and 128th respectively) than they do in the Global Gender Gap Index, which gives high weight to institutional aspects such as the share of women in parliament. This paper aims to investigate the impact of the gap between the law and custom on social change, by analyzing the cases of Rwanda and Nicaragua. Specifically, this study examines the areas of women’s rights, land ownership, and domestic violence to identify the extent to which the gap between the law and custom influences the everyday lives of women in these countries. The analysis indicates that it is necessary to find a balance between the law and custom that promotes change while reducing conflicts. This requires a moderate law that aligns with customs or surpasses customs by a moderate margin. Moreover, the presence of enforcement mechanisms is crucial in effecting change from customary practices to new laws. In this regard, active women’s movements can serve to exert pressure for effective enforcement, which eventually can bridge the gap between the law and custom. [ABSTRACT FROM AUTHOR]

Community mobilisation is recognised as an important strategy to shift inequitable gender norms and ensure an enabling environment to prevent gender-based violence (GBV). Yet there is a need to better understand the factors that facilitate effective community activism in particular contexts. Although fundamental to the success of mobilisation programmes, there is also limited appreciation of the experiences and agency of engaged community activists. This paper draws on qualitative evaluations from two community mobilisation GBV prevention programmes: the Gender Violence in the Amazon of Peru (GAP) Project and the Indashyikirwa programme in Rwanda. In Peru, participatory data was collected, in addition to baseline and endline interviews with 8 activists. In Rwanda, baseline and endline interviews and observations were conducted with 12 activists, and interviews were conducted with 8 staff members. The data was thematically analysed, and a comparative case study approach was applied to both data sets. The comparative study identified similar programmatic aspects that could hinder or enable activist's engagement and development, and how these are embedded within contextual social and structural factors. We discuss these insights in reference to the current emphasis in public health on individualistic programming, with insufficient attention to how wider environments influence violence prevention programming. [ABSTRACT FROM AUTHOR]

Can divide-and-rule colonial policy be responsible for contemporary ethnic tension? This paper empirically investigates the role of a divisive and extractive colonial policy on Hutu–Tutsi discord in Rwanda and Burundi. It shows that Hutu with a family history of subjugation to forced labour by Tutsi chiefs are less trusting of Tutsi today and less willing to partner with Tutsi for a cooperative task. This may have implications for agriculture insurance agreements because Hutu are more agrarian and Tutsi are more pastoral. Indeed, Hutu with a forced labour family history make fewer inter-household insurance agreements and are more likely to experience default. [ABSTRACT FROM AUTHOR]

Infant and young child feeding (IYCF) plays a crucial role in early childhood growth and development. This study summarizes recent IYCF practices in multiple refugee settings and compares them to those in the host countries. We analyzed 203 surveys conducted among refugees residing in 15 countries and 120 unique sites and assessed eight IYCF indicators available from those surveys. A total of 146 surveys were conducted in Eastern and Southern Africa (ESA) and 50 in Western and Central Africa (WCA) regions. The median prevalence across surveys of all four indicators describing intake of breast milk was relatively high: 96.6% for ever breastfed, 81.2% for initiation of breastfeeding within 1 h of birth, 76.9% for exclusive breastfeeding 0–5 months, and 75.0% for continued breastfeeding 12–23 months. The median prevalence of early initiation and exclusive breastfeeding was markedly higher in ESA than in WCA (85.0% vs. 37.5% and 83.5% vs. 56.1%, respectively). Conversely, the overall median prevalence of timely introduction of solid and semisolid foods and flesh food consumption was low: 51.8% and 16.1%, respectively. Flesh food consumption was higher in WCA than in ESA (27.4% vs. 11.6%). The median prevalence of mixed milk feeding at 0–5 months and bottle feeding was very low: 2.4% and 3.8%, respectively. Indicators describing breast milk intake were generally either similar or higher in refugees than in the host country populations, whereas the other indicators were generally higher in the host populations than in refugees. The low prevalence of timely introduction of solids and of flesh food consumption in refugees is concerning and requires substantial improvement. Key Messages: Infant and young child feeding practices need to be monitored in refugee settings where access to nutritious foods may be limited.We analyzed infant and young child feeding data from 203 population representative surveys in refugee settings conducted during 2013–2019.Prevalence of indicators describing breast milk consumption in refugees was relatively high overall and similar or higher than in local populations.Prevalence of indicators describing the consumption of other complementary foods or liquids in refugees was low overall and generally lower than in the host populations, documenting a need for improved access to such foods and change in feeding practices. [ABSTRACT FROM AUTHOR]

This paper explores instances of agency in women's responses to intimate partner violence (IPV) in Rwanda. The literature on women's responses to IPV conceptualises agency primarily as an individual's capacity to take action by reporting violence or leaving a relationship, obscuring other ways women may respond to violence in contexts where reporting or leaving are unlikely. We aim to replace this narrow conceptualisation of agency with a social constructivist focus on the meanings women attribute to possible IPV responses. We draw on data from a study of IPV in Rwanda, which includes semi-structured interviews with women experiencing violence and four focus group discussions with women community members (n= 39). Our findings highlight sociocultural, economic, political-legal and historical constraints that shape women's actions in this context. In relation to these constraints, women describe four possible responses to IPV: reporting the violence; seeking emotional support; ‘fighting back’ against violence; or remaining silent. While reporting and leaving violent relationships are identified, women also discuss the social constraints that make these actions extremely difficult. In designing effective strategies, we conclude that public health strategies need to consider women's understandings of their own actions, particularly in social contexts where certain actions may be constrained. [ABSTRACT FROM AUTHOR]

Problem Management Plus (PM+) is a low-intensity psychological intervention developed by the World Health Organization that can be delivered by nonspecialists to address common mental health conditions in people affected by adversity. Emerging evidence demonstrates the efficacy of PM+ across a range of settings. However, the published literature rarely documents the adaptation processes for psychological interventions to context or culture, including curriculum or implementation adaptations. Practical guidance for adapting PM+ to context while maintaining fidelity to core psychological elements is essential for mental health implementers to enable replication and scale. This paper describes the process of contextually adapting PM+ for implementation in Rwanda, Peru, Mexico and Malawi undertaken by the international nongovernmental organisation Partners In Health. To our knowledge, this initiative is among the first to adapt PM+ for routine delivery across multiple public sector primary care and community settings in partnership with Ministries of Health. Lessons learned contribute to a broader understanding of effective processes for adapting low-intensity psychological interventions to real-world contexts. Key implications for practice PM+ can be contextualised based on cultural and implementation considerations while maintaining core psychological elements across different settings. The adaptation of PM+ for local health systems and articulation of practical guidance on implementation for routine care is essential. Partnerships across implementing sites are fundamental for iterative PM+ adaptation and provide opportunities for sharing lessons learned. [ABSTRACT FROM AUTHOR]

Background: This paper describes our work to create and validate a new method for cross-cultural and sex-specific function assessment that avoids the major problems with existing methods., Methods: We used free listing to learn about tasks important to local people. Community-specific function questionnaires based on these tasks were then created and used in community-based surveys. The survey results were used to assess the questionnaires' internal reliability (Cronbach's alpha), combined test-retest and across-interviewer reliability using repeat interviews, and (in Uganda) criterion validity by comparing assessment by self to assessments by cohabiting adults., Results: Field trials of this approach were conducted in rural Rwanda and Uganda. Differences between tasks identified by free listing were greater between sexes than sites. Cronbach's alphas for male and female questionnaires were respectively 0.815 and 0.822 in Rwanda and 0.886 and 0.881 in Uganda. Pearson correlations for combined test-retest and across-interviewer reliability were respectively 0.469 and 0.640 for Rwandan men and women and 0.797 and 0.871 in Uganda. Correlation between self-assessment and cohabiting adults was 0.904., Conclusions: We have developed an alternative to the existing approach of adapting western function instruments to other cultures and situations. The field trials have demonstrated that this approach is rapid, feasible and can yield valid and reliable instruments. Developing instruments locally avoids the problems of limited local relevance and appropriateness associated with adapting western instruments. Although each instrument created in this way is culturally bound, they are "cross-cultural" in the sense that each refers to the tasks most important to local people. This approach should prove useful for both researchers and aid agencies working in non-western countries.

Abstract To contribute to understanding the association between silence and suffering in the context of war and political repression, this study sheds light on the meaning-making process and explores the underlying mechanisms by which silence leads to suffering and how this suffering could be alleviated. The ethnographic research was conducted in 2015–2016, with 43 participants from northern Rwanda, who survived massacres after the 1994 genocide but were prevented from speaking about the experience by political constraints. The findings first describe their suffering, through grief, social isolation and loss of meaning in life and death (expressed as existential questions). Their suffering was worsened by 'unspeakability'; that is, the political context that prevents victims from speaking freely about their war experience, including discussion of those who killed and those who were killed. Unspeakability exacerbated suffering since participants were obstructed from applying ready narratives (e.g. funerary rituals, traditional reconciliation systems) or constructing their own narratives which could ordinarily help them to process mourning and reconciliation and to make sense of the loss. They selectively employed silence for coping and protection, avoiding speaking about the past to maintain everyday life. However, at the same time, unprocessed mourning remained a serious problem, resulting in mental health problems such as hallucinations of the spirits of the dead; participants expressed a strong need for mourning rituals. Overall, this paper highlights the ways in which the suffering of the silenced population worsens when meaning-making processes are obstructed. To alleviate the suffering, it is essential to secure mourning rituals for all survivors, particularly those who, as part of the defeated group of war, are silenced and marginalized in history. Highlights • Elaborates suffering of silenced people in post-genocide Rwanda. • Examines how silence exacerbates suffering and what support could be helpful. • Reveals the obstructed meaning-making process by which silence worsens suffering. • Recommends mourning rituals for silenced survivors to make sense of the loss. [ABSTRACT FROM AUTHOR]

Rwanda remains in the eastern camp of ethnic ideas and projects of a ‘nation’ inasmuch as it is dominated by cultural as opposed to civic/political elements. Although the Rwandan attempt remains exclusive internally, it does not affirm the validity of an idealised Kohnian dichotomy between ‘exclusive’ ethnic nationalism and ‘inclusive’ civic nationalism. To avoid the trap of a bi-polar and value-ladden division, while preserving the useful insights of Kohn, the paper calls for a re-conceptualisation of nation-building projects along the continuum of their relative inclusiveness/exclusiveness, both internally (who shapes the ‘idea of nation’) and externally (the boundaries of nation). [ABSTRACT FROM AUTHOR]

Background: The popular use of traditional medicine in low-income settings has previously been attributed to poverty, lack of education, and insufficient accessibility to conventional health service. However, in many countries, including in Rwanda, the use of traditional medicine is still popular despite the good accessibility and availability of conventional health services. This study aims to explore why traditional medicine is popularly used in Rwanda where it has achieved universal health coverage. Methods: The qualitative study, which included in-depth interviews and participant observations, investigated the experience of using traditional medicine as well as the perceived needs and reasons for its use in the Musanze district of northern Rwanda. We recruited 21 participants (15 community members and 6 traditional healers) for in-depth interviews. Thematic analysis was conducted to generate common themes and coding schemes. Results: Our findings suggest that the characteristics of traditional medicine are responding to community members' health, social and financial needs which are insufficiently met by the current conventional health services. Participants used traditional medicine particularly to deal with culture-specific illness – uburozi. To treat uburozi appropriately, referrals from hospitals to traditional healers took place spontaneously. Conclusions: In Rwanda, conventional health services universally cover diseases that are diagnosed by the standard of conventional medicine. However, this universal health coverage may not sufficiently respond patients' social and financial needs arising from the health needs. Given this, integrating traditional medicine into national health systems, with adequate regulatory framework for quality control, would be beneficial to meet patients' needs. [ABSTRACT FROM AUTHOR]

Background: There is considerable interest in community organising and activism as a strategy to shift patriarchal gender norms, attitudes and beliefs and thus reduce intimate partner violence (IPV). Yet there is limited insight into how activism actually translates into reduced violence, including how aspects of programme implementation or cultural context may affect impact. This study evaluates the community activism/mobilisation portion of Indashyikirwa, a multi-component, IPV prevention programme implemented in rural Rwanda. The activism part of Indashyikirwa was based on SASA!, a promising program model from Uganda with demonstrated effectiveness.Methods: We implemented two separate cross-sectional surveys as part of a larger community randomised controlled trial to assess the impact of the community portion of Indashyikirwa on preventing physical and/or sexual IPV and other secondary outcomes at a community level. The survey consisted of a random household-based sample of 1400 women and 1400 men at both waves. Surveys were conducted before community-level activities commenced and were repeated 24 months later with a new cross-sectional sample. Longitudinal, qualitative data were collected as part of an embedded process evaluation.Results: There was no evidence of an intervention effect at a community level on any of the trial's primary or secondary outcomes, most notably women's experience of physical and/or sexual IPV from a current male partner in the past 12 months (adjusted odds ratio (aOR) = 1.25; 95% confidence interval (CI) = 0.92-1.70, P = 0.16), or men's perpetration of male-to-female physical and/or sexual IPV (aOR = 1.02; 95% CI = 0.72-1.45, P = 0.89). Process evaluation data suggest that delays due to challenges in adapting and implementing SASA!-style activites in rural Rwanda may account for the trial's failure to measure an effect. Additionally, the intervention strategy of informal activism was not well suited to the Rwandan context and required considerable modification.Conclusions: Failure to reduce violence when implementing an adaptation of SASA! in rural Rwanda highlights the importance of allowing sufficient time for adapting evidence-based programming (EBP) to ensure cultural appropriateness and fidelity. This evaluation held little chance of demonstrating impact since the project timeline forced endline evaluation only months after certain elements of the programme became operational. Donors must anticipate longer time horizons (5 to 7 years) when contemplating evaluations of novel or newly-adapted programmess for reducing IPV at a population level. These findings also reinforce the value of including embedded process evaluations when investing in rigorous trials of complex phenomena such as community activism.Trial Registration: ClinicalTrials.gov, NCT03477877. [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: Past research suggests that culture shapes the way psychopathology is experienced and expressed. Standard psychiatric assessment instruments may therefore not capture the same underlying constructs in different contexts. The present study investigated the factor structure of a standard depression scale in a sample of Rwandan genocide survivors. Methods: One hundred ninety six Rwandan adults provided socio-demographic information and completed the Center for Epidemiological Studies-Depression scale (CES-D), one of the most widely used self-report instruments assessing depressive symptoms, as part of a larger study on well-being and mental health in Rwanda. Results: A two-factor solution provided the best fit for these CES-D data. The first factor corresponded to general depressive symptoms (including depressed affect, somatic symptoms, and interpersonal concerns) and explained 37.20 % of the variance. The second factor included items assessing positive affect and explained 8.68 % of the variance. Conclusions: The two-factor solution found in the present study deviates from the commonly reported four-factor structure, but is consistent with studies showing that depressed affect and somatic symptoms may not be experienced as distinct in certain non-Western and minority cultural groups. [ABSTRACT FROM AUTHOR]