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Background: Delivery of effective healthcare is contingent on the quality of communication between the patient and the healthcare provider. Little is known about primary healthcare providers’ perceptions of communication with patients in Rwanda. Aim: To explore providers’ perceptions of patient-provider communication (PPC) and analyse the ways in which providers present and reflect on communication practice and problems. Methods: Qualitative, in-depth, semi structured interviews with nine primary health care providers. An abductive analysis supplemented by the framework method was applied. A narrative approach allowed the emergence of archetypical narratives on PPC. Results: Providers shared rich reflections on the importance of proper communication with patients and appeared committed to making their interaction work optimally. Still, providers had difficulty critically analysing limitations of their communication in practice. Reported communication issues included lack of communication training as well as time and workload issues. Two archetypes of narratives on PPC issues and practice emerged and are discussed. Conclusion: While providers’ narratives put patients at the centre of care, there were indications that patient-provider communication training and practice need further development. In-depth exploration of highlighted issues and adapted strategies to tackle communication drawbacks are prerequisites to improvement. This study contributes to the advancement of knowledge related to communication between the patient and the provider in a resource-limited setting. [ABSTRACT FROM AUTHOR]

Background: External supervision of primary healthcare facilities in low- and middle-income countries often has a managerial main purpose in which the role of support for professional development is unclear. Aim: To explore how Rwandan primary healthcare supervisors and providers (supervisees) perceive evaluative and formative functions of external supervision. Design: Qualitative, exploratory study. Data: Focus group discussions: three with supervisors, three with providers, and one mixed (n = 31). Findings were discussed with individual and groups of supervisors and providers. Results: Evaluative activities occupied providers’ understanding of supervision, including checking, correcting, marking and performance-based financing. These were presented as sources of motivation, that in self-determination theory indicate introjected regulation. Supervisors preferred to highlight their role in formative supervision, which may mask their own and providers’ uncontested accounts that systematic performance evaluations predominated supervisors’ work. Providers strongly requested larger focus on formative and supportive functions, voiced as well by most supervisors. Impact of performance evaluation on motivation and professional development is discussed. Conclusion: While external supervisors intended to support providers’ professional development, our findings indicate serious problems with this in a context of frequent evaluations and performance marking. Separating the role of supporter and evaluator does not appear as the simple solution. If external supervision is to improve health care services, it is essential that supervisors and health centre managers are competent to support providers in a way that transparently accounts for various performance pressures. This includes delivery of proper formative supervision with useful feedback, maintaining an effective supervisory relationship, as well as ensuring providers are aware of the purpose and content of evaluative and formative supervision functions. [ABSTRACT FROM AUTHOR]

What works well in primary care education in your locality, region or country? • In this case, we focus on primary care research education. Twinning of individual Ph.D. students under strong institutional south-south or south-north partnerships may help build capacity for locally anchored primary care research potentially unaddressed by other projects and organisations, as well as enforce the quality of research and learning outcomes What challenges have you faced? • The high level of interdependency and sharing between the Ph.D. twins entails risks for project completion. Also, differences between the twins, their institutions and their country regulations pose challenges both for formal requirements and daily collaboration How have you addressed them? • Advocacy, timely planning, institutional commitment and information sharing at administrative levels help facilitate formal and informal institutional collaboration. Social investment, friendship, flexibility and alignment of expectations of the twins help streamline daily collaboration. Local employment of southern twin and inclusion of bilateral co-supervisors anchor the project locally What is the generalisable learning? • This pilot of matching and twinning Ph.D. students shows potential for equitable research capacity building in resource-constrained settings. It extends principles of collaborative learning to the doctoral level where the Ph.D. twins may compensate and challenge each other as well as share benefits and risks, successes and failures, joys and frustrations in their work, synergistically empowering one another as international collaborators, communicators and researchers [ABSTRACT FROM AUTHOR]

What works well in primary care education in your locality, region or country? • The new undergraduate social and community medicine training (iSOCO) in Rwanda focuses on crosscutting skills, knowledge and attitudes in primary health care delivery. What challenges have you faced? • Challenges faced include programme sustainability (PHC), large student group teaching, limited resources and students being unfamiliar with the new online teaching platform with unstable internet accessibility. How have you addressed them? • The iSOCO development and teaching team was motivated to work with the limited resources available and to develop an innovative training with available resources. Strong focus of the Ministry of Health on PHC, the need of the College of Medicine and Health Sciences to become more socially accountable and long-term commitment of external partners increased the programme sustainability. What is the generalisable learning? • When students are exposed to the principles of PHC and social and community medicine early in the medical education, it is more likely they will become patient-centred and community-oriented health care providers who are good communicators, collaborators, managers, scholars, health advocates and professionals, as described in the ‘desired Rwandan health care. provider' [ABSTRACT FROM AUTHOR]

Background: External supervision of primary health care facilities to monitor and improve services is common in low-income countries. Currently there are no tools to measure the quality of support in external supervision in these countries. Aim: To develop a provider-reported instrument to assess the support delivered through external supervision in Rwanda and other countries. Methods: "External supervision: Provider Evaluation of Supervisor Support" (ExPRESS) was developed in 18 steps, primarily in Rwanda. Content validity was optimised using systematic search for related instruments, interviews, translations, and relevance assessments by international supervision experts as well as local experts in Nigeria, Kenya, Uganda and Rwanda. Construct validity and reliability were examined in two separate field tests, the first using exploratory factor analysis and a test-retest design, the second for confirmatory factor analysis. Results: We included 16 items in section A ('The most recent experience with an external supervisor'), and 13 items in section B ('The overall experience with external supervisors'). Item-content validity index was acceptable. In field test I, test-retest had acceptable kappa values and exploratory factor analysis suggested relevant factors in sections A and B used for model hypotheses. In field test II, models were tested by confirmatory factor analysis fitting a 4-factor model for section A, and a 3-factor model for section B. Conclusions: ExPRESS is a promising tool for evaluation of the quality of support of primary health care providers in external supervision of primary health care facilities in resource-constrained settings. ExPRESS may be used as specific feedback to external supervisors to help identify and address gaps in the supervision they provide. Further studies should determine optimal interpretation of scores and the number of respondents needed per supervisor to obtain precise results, as well as test the functionality of section B. [ABSTRACT FROM AUTHOR]

Background: Skill-mix imbalance is a global concern for primary healthcare in low-income countries. In Rwanda, primary healthcare facilities (health centres, HCs) are predominantly led by nurses. They have to diagnose a multitude of health complaints. Whether they feel capable of undertaking this responsibility has yet to be explored. Aim: This study explored how healthcare providers (HPs) at Rwandan HCs perceived their capability in the diagnostic practice. Setting: Rural and urban HCs in Muhanga district, Rwanda. Method: Qualitative, semi-structured interviews with nurses and clinical officers, and observations of consultations were made. Findings were analysed thematically. Results: Rwandan HPs were confident in their competences to perform diagnostic procedures although nurses felt that the responsibilities lay beyond their professional training. Clinical officers believed that their professional training prepared them to function competently and autonomously in the diagnostic practice, although all HPs experienced a high dependency on medical history taking, physical examination and laboratory tests for reaching a diagnosis. Resource constraints (time, rooms and laboratory tests) were seen as a barrier to perform diagnostic tasks optimally, and HPs experienced in-service training and supervision as insufficient. They increased their diagnostic competences through work experience, self-learning and supportive peer collaboration. Conclusion: Clinical officers perceived themselves as capable in the diagnostic practice. Nurses may compensate for insufficient school training through in-service learning opportunities and feel capable in the diagnostic practice. Formative mentorship schemes and tailored education may prove valuable, but further research on how to improve HPs' diagnostic capability in Rwanda's primary healthcare sector is needed. [ABSTRACT FROM AUTHOR]

Objective: To identify, adapt and validate a measure for providers' communication and interpersonal skills in Rwanda.Methods: After selection, translation and piloting of the measure, structural validity, test-retest reliability, and differential item functioning were assessed.Results: Identification and adaptation: The 14-item Communication Assessment Tool (CAT) was selected and adapted.Validity and Reliability Testing: Content validation found all items highly relevant in the local context except two, which were retained upon understanding the reasoning applied by patients. Eleven providers and 291 patients were involved in the field-testing. Confirmatory factor analysis showed a good fit for the original one factor model. Test-retest reliability assessment revealed a mean quadratic weighted Kappa = 0.81 (range: 0.69-0.89, N = 57). The average proportion of excellent scores was 15.7% (SD: 24.7, range: 9.9-21.8%, N = 180). Differential item functioning was not observed except for item 1, which focuses on greetings, for age groups (p = 0.02, N = 180).Conclusion: The Kinyarwanda version of CAT (K-CAT) is a reliable and valid patient-reported measure of providers' communication and interpersonal skills. K-CAT was validated on nurses and its use on other types of providers may require further validation.Practice Implication: K-CAT is expected to be a valuable feedback tool for providers in practice and in training. [ABSTRACT FROM AUTHOR]