Intimate Partner Violence Among Rwandan Women With HIV: A Cross-Sectional Study.

ABSTRACT: In Rwanda, women have higher incidence of HIV and intimate partner violence (IPV). This study aimed to estimate the prevalence of IPV among women living with HIV (WWH) in Rwanda and measure the difference in psychological outcomes, demographic data, and HIV-related outcomes using a cross-sectional, descriptive, observational design. A convenience sample of 162 Rwandan WWH were purposefully recruited to participate. The study collected demographic data and data about IPV, depression, HIV-related stigma, coping, self-esteem, and hope. The prevalence of any form of IPV in the sample was 27% with psychological IPV being the most prevalent. Demographic data had no statistical significance with the prevalence of IPV. WWH who experienced IPV had higher HIV stigma, lower coping self-efficacy, lower self-esteem, and less hope and worse HIV psychological outcomes. Further studies are needed to look into the correlation between the two and interventions addressing IPV prevention.

Teaching family planning to nurse and midwife students: A constructivist grounded theory study.

AIM: This study aimed to describe nurse/midwife educators' understanding and enactment of teaching family planning methods with nursing/midwifery students in educational programs in Rwanda. More precisely, the aim of this study was to generate a substantive theory that explains how nurse/midwife educators introduce family planning methods into their teaching practice to facilitate learning among nurse/midwife students in Rwanda. BACKGROUND: High maternal mortality remains a global health issue. In 2017, approximately 295,000 women worldwide died from complications related to pregnancy or childbirth and 94% of these maternal deaths occurred in low-income countries. Evidence shows that family planning improves maternal health outcomes and significantly contributes to reducing maternal mortality. Low family planning uptake is partly attributed to inadequate education of healthcare providers to provide family planning services. DESIGN: This study followed the constructivist grounded theory methodology articulated by Kathy Charmaz (2006; 2014). METHODS: The primary data source was individual semi-structured interviews with 25 nurse/midwife educators recruited from all the schools/faculties/departments of nursing and midwifery in Rwanda, augmented with written documents related to family planning education in nursing/midwifery preservice programs. RESULTS: The substantive Theory that emerged from the data analysis indicated that the process of teaching family planning in preservice nursing/midwifery education among nurse/midwife educators has three phases: preparing, facilitating and evaluating. Factors that had an impact on the process and actions that nurse/midwife educators undertook to address the challenges related to those factors were identified. The main influential factors that had a significant impact on nurse/midwife educators' ability to teach family planning are contextual factors and personal factors related to the nurse/midwife educators. The contextual factors included the availability of resources, student-teacher ratio, number of students in clinical placements and the time allocated to the family planning unit. The personal factors related to the nurse/midwife educators included knowledge, skills, confidence, attitude, beliefs and moral values toward family planning methods. CONCLUSION: These study findings generated valuable knowledge that can guide the improvement of teaching family planning in preservice nursing/midwifery programs in Rwanda and other limited-resource countries and contexts. With the insights provided by this study, future research should investigate strategies to overcome highlighted barriers, increase nurse/midwife educators' expertise in teaching family planning and enhance the preparedness of nurse/midwife students on some family planning methods identified in this study.

A framework for capacity enhancement of Rwandan nurse educators and preceptors facilitating nursing students to learn pediatric pain management.

INTRODUCTION: In low- and middle- income countries like Rwanda, children are most likely to suffer from painful and life-limiting conditions due to various factors predominant in these settings. Adequate pre-licensure pain management training can improve pain relief nursing practices. Educators and nurses in practice have a responsibility to teach the soon-to- be nurses for holistic competent nursing care of children, emphasizing the importance of and addressing child's suffering, yet inconsistencies were reported in what was taught regarding pediatric pain management from a theoretical perspective by nurse educators as compared to their counterparts in clinical settings in Rwanda. DESIGN: This study applied a qualitative approach using group discussions based on nominal group technique (NGT) to develop and validate a conceptual framework supporting the capacity enhancement of nurse educators and preceptors facilitating students' learning about pediatric pain management in Rwanda. METHODS: NGT meetings were conducted with academic nurses (n = 8), nurse clinicians (n = 4), and nursing students (n = 2) during a 2-day workshop to identify strategies, discuss the relevance of each strategy and to agree on key concepts of a framework for improving the ability of nurse educators and preceptors to teach PPM to nursing students. After four weeks another round of NGT meetings were done with nursing faculty (n = 6), academic nurse leaders (n = 3), nurse preceptors (n = 2), clinical nurse leaders (n = 2), a nurse leader from a regulatory body (n = 1), and nursing student (n = 1) to validate the developed framework. FINDINGS: Four main strategies corresponding to the key concepts were mapped in a framework. Participants had a consensual agreement on the importance of the developed framework, they confirmed its completeness and practicality. In addition, participants found that the developed framework is logical, and confirmed that it is applicable for its purpose. CONCLUSION: The developed framework presents an opportunity to respond to the gaps in nursing pain education in the context of limited resources settings such as Rwanda. It can also be applied in nursing practice and nursing research, aligning with the need of improving the quality of care of suffering children. Furthermore, the framework can be adapted and utilized to meet the needs of healthcare professionals other than nurses. CLINICAL RELEVANCE: Strategies are suggested to improve the ability of nurse educators and preceptors in clinical settings to facilitate the acquisition of pediatric pain management competencies by the next generation of nurses. Future Rwandan nurses could then use the competencies acquired to provide optimal health care to children with pain in the best way possible during their practices.

Sexuality and Sexual and Reproductive Health Depiction in Social Media: Content Analysis of Kinyarwanda YouTube Channels.

BACKGROUND: Social media platforms such as YouTube can be used to educate people of reproductive age about healthy and nonrisky sexual and reproductive health (SRH) practices and behaviors. However, there is a paucity of evidence to ascertain the authenticity of sexuality and SRH content on Kinyarwanda YouTube, making it difficult to determine the extent to which these topics are covered, the characteristics of available videos, and the themes covered by these videos. OBJECTIVE: The aims of this study were (1) to determine the extent to which YouTube channels in Kinyarwanda-language videos address sexuality and SRH issues, identify the general characteristics of the available videos (type of video, when published, intention for the audience, and content focus), and the aspects of sexuality and SRH covered; and (2) to identify the themes covered by retrieved Kinyarwanda videos, and the extent to which the channels have been used to communicate issues of sexuality and SRH during the COVID-19 pandemic. METHODS: Using a content analysis approach, we searched Kinyarwanda YouTube channels to analyze videos about sexuality and SRH. The adopted framework for data collection from social media platforms builds on three key steps: (1) development, (2) application, and (3) assessment of search filters. To be included, an audio and/or visual video had to be in Kinyarwanda and the video had to be directed to the general public. Descriptive statistics (frequency and percentages) were computed to characterize the basic characteristics of retrieved channels, portrayal of the videos, and presentation of sexuality and SRH themes that emerged from retrieved videos. Further analysis involved cross-tabulations to explore associations between the focus of the channel and the date when the channel was opened and the focus of the channel and who was involved in the video. RESULTS: The YouTube search retrieved 21,506 videos that tackled sexuality and SRH topics. During the COVID-19 pandemic, there was a 4-fold increase (from 7.2% to 30.6%) in channels that solely focused on sexually explicit content. The majority of the 1369 retrieved channels (n=1150, 84.0%) tackled the topic of sexuality, with sexually explicit content predominantly found in the majority of these videos (n=1082, 79%), and only 16% (n=287) of the videos covered SRH topics. CONCLUSIONS: This is the first study to analyze the use of YouTube in communicating about sexuality and SRH in the Kinyarwanda language. This study relied on videos that appeared online. Further research should gather information about who accesses the videos, and how channel owners and individuals involved in the videos perceive the impact of their videos on the Rwandan community's sexuality and SRH.

Dehumanizing language, motherhood in the context of HIV, and overcoming HIV stigma - the voices of Rwandan women with HIV: A focus group study.

BACKGROUND: Stigma is an underlying cause of health inequities, and a major barrier to HIV prevention, care, and treatment. Experiences of HIV stigma have been shown to reduce engagement in care across the HIV care continuum, from testing and diagnosis to long-term retention in care and anti-retroviral therapy adherence. In Rwanda, approximately 130,000 women are living with HIV, representing a prevalence rate (3.7%) which is substantially higher than Rwandan men (2.2%). Both the national Rwanda and City of Kigali HIV and AIDS strategic plans identify stigma as a key concern for reducing the burden of HIV. OBJECTIVES: The first objective of this study was to understand the sources of HIV-related stigma among women living with HIV in Rwanda. The second objective was to understand the cultural, linguistic, and contextual context of HIV-related stigma and the intersection of HIV-related stigma to the HIV care continuum (engagement in care, medication/treatment adherence) among women with HIV in Rwanda. DESIGN: This study used a cross-sectional, qualitative design. SETTING AND PARTICIPANTS: Three-three women from urban and rural settings in Rwanda were recruited from public HIV treatment and care centers to participate in this study. METHOD: Focus groups discussions, guided by a structured interview guide, were used to collect qualitative data. Framework analysis was used to analyze the data, which was collected during July 2018. RESULTS: The participants in this study highlighted that Rwandan women with HIV experience all forms of stigma - enacted, anticipated, perceived, and internalized - associated with HIV as well as structural stigma. Further, three major themes - dehumanizing language, importance of motherhood in the context of HIV, and overcoming HIV stigma - emerged from the data. CONCLUSION: The results of this study are among the few to give voice and perspective to the stigma experiences of Rwandan women with HIV. The women with HIV participating in this study shed light on the pervasive and culturally constructed effects of stigma that continue to exist. Further, the findings from this study highlighted the significant intersection of the role dehumanizing language experienced by Rwandan women with HIV. Additionally, the intersectional identities of being a woman with HIV and a mother and their relationship to societal and cultural norms and expectations must be considered concurrently. Finally, the beneficial effects of support groups was identified as key in helping Rwandan women with HIV to accept self.

Nurses' and nurse educators' experiences of a Pediatric Nursing Continuing Professional Development program in Rwanda.

OBJECTIVES: In 2016, a Pediatric Nursing Continuing Professional Development (PNCPD) program was created and implemented in Kigali, Rwanda, through the Training, Support, and Access Model (TSAM) for Maternal, Newborn, and Child Health (MNCH). This partnership project between Canada and Rwanda provided pediatric nursing education to forty-one Rwandan nurses and nurse educators in 2018 and 2019. The objective of this research study was to explore the experiences of nurses and nurse educators applying pediatric knowledge and skills to academic and clinical settings after participating in the PNCPD program. METHODS: This study was situated within an interpretive descriptive perspective to explore the ways in which knowledge gained during the PNCPD program in Rwanda was applied by nurses and nurse educators in their nursing practice, both academically and clinically. Data was collected through individual interviews. Inductive content analysis was used for data analysis. RESULTS: The analysis of the interviews resulted in the emergence of five themes: Transformations in Pediatric Nursing Practice, Knowledge Sharing, Relationship-Based Nursing, Barriers and Facilitators to Knowledge Implementation, and Scaling-up PNCPD within the Health System. CONCLUSIONS: The results of this study have the potential to inform positive changes to child health care in Rwanda, including scaling up pediatric nursing education to other areas of the healthcare system.

Exploring factors affecting the facilitation of nursing students to learn paediatric pain management in Rwanda: A descriptive qualitative study.

Nurse educators and nurse preceptors play a fundamental role in facilitating nursing students' acquisition and utilization of professional competencies. Previous studies about key elements for teaching and learning about pain in nursing education programs include students' personal characteristics and previous experiences; educators' knowledge, skills, and beliefs; learners' exposure to leaders in pain education; and curricular pain content and delivery approaches. These studies were mainly carried out in developed countries, with a context of educational and health care systems different from those of developing countries. The current study explores academics', clinical nurse preceptors', and nursing students' perceptions about factors influencing the facilitation of nursing students' competency for paediatric pain management in Rwanda. A qualitative descriptive exploratory design was used in this study that utilized in-depth interviews with six nurse educators and eight nurse preceptors, and focus group discussions with nineteen senior year nursing students. The study setting included five sites: two academic institutions and three clinical settings. Narratives from participants were transcribed verbatim and analysed using thematic analysis. The analysis yielded six themes describing factors that affected the facilitation of students' learning about paediatric pain management. The themes included student motivation, facilitators' attributes, collaboration between academics and clinicians, nurses' limited autonomy for decision-making regarding PPM practices, shortage of human and material resources, and educational qualification. Knowing these factors is essential as it provides an opportunity to design targeted interventions aimed to enhance the capacity of nurse educators and clinical nurse preceptors involved in teaching nursing students about paediatric pain management.

Double Jeopardy: Young adult mental and physical health outcomes following conception via genocidal rape during the 1994 genocide against the Tutsi in Rwanda.

Rwandans conceived by rape during the 1994 genocide against the Tutsi have endured a violent beginning and a troubled childhood. Given compelling evidence of the influence of prenatal environments and adverse childhood experiences (ACEs) on future health, these individuals are at high risk of poor mental and physical health outcomes. The purpose of the study was to characterize mental and physical health outcomes in young adults who were exposed prenatally to maternal stress due to the genocide in general and those conceived by genocidal rape, and to determine whether ACEs compound these effects. Ninety-one 24-year-old Rwandans - 30 conceived by genocidal rape, 31 born of genocide survivors not raped, and a control group of 30 born of women with neither exposure - completed the Adverse Childhood Experiences International Questionnaire and measures of multiple physical and mental health characteristics. Data were collected from March 7 to April 6, 2019. Findings demonstrated that 1) individuals conceived during the genocide had poorer mental function (p = 0.002) and higher scores in post-traumatic stress disorder (PTSD), anxiety, depression, physical function, pain intensity, and sleep disturbance compared to young adults who were not exposed to genocide (all p < 0.033); 2) individuals conceived by genocidal rape reported more depression, PTSD, and pain interference compared to those prenatally exposed to maternal genocide stress only (all p < 0.008); and 3) among the group conceived via genocidal rape, the effects of prenatal exposures on depression, physical function, pain intensity and pain interference were exacerbated by ACEs (all p < 0.041). Being conceived during genocide, especially through genocidal rape, is associated with poor adult physical and mental health. The role of ACEs in exacerbating prenatal genocide exposure highlights opportunities for interventions to reduce these effects.

Nursing Theory in the Quest for the Sustainable Development Goals.

The 17 United Nations Sustainable Development Goals (SDG) are intended to promote a safe, healthy, and equitable world by the year 2030. Nurses are at the forefront of realizing the 2030 agenda through concerned citizenship and professional leadership. Nursing theory informs knowledge development and theory-guided practice essential for nurses working in all domains and in all nations. Although all extant nursing theories are relevant, a select few are discussed in detail to make explicit the links between theory and SDG realization. Middle-range theories are also valuable in helping to contextualize nursing practice through the lens of the SDGs. The SDGs address five themes - People, Planet, Peace, Prosperity, and Partnership - and theory remains vital to ensure nurses working in all settings are equipped to meet the needs of humanity and the world, now and in the future.

Genocide Rape Trauma: A Conceptual Framework for Understanding the Psychological Suffering of Rwandan Survivors.

In 1994, the Rwandan genocide claimed the lives of approximately 1 million Tutsi and moderate Hutu citizens. Systematic rape was a strategic component of the Hutu extremist plan to eradicate the Tutsi minority population. This involved collective and repeated sexual assaults with brutal violence, public humiliation, and torture. This article maps the ongoing psychological impact on Rwandan genocide rape survivors and identifies implications for international nursing practice. The research formalizes their narratives, identifying a number of interconnected elements that combine to produce myriad forms of chronic psychological suffering in the Rwandan context. This work in turn reveals the specific needs of these survivors that may be addressed by nursing. It allows nurses, as experts in managing the human responses to health and illness, to develop a more complete understanding of psychological suffering as it pertains to vulnerable populations during and in the wake of extreme social conflict. This clarifies the roles of nurse educators, clinicians, and policy advocates as key agents in providing genocide rape survivors with the resources and expertise needed to effectively manage their ongoing trauma.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda.

BACKGROUND: The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. METHODS: The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. RESULTS: In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. CONCLUSION: The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

Building Nursing and Midwifery Capacity Through Rwanda's Human Resources for Health Program.

Global disparities in the quantity, distribution, and skills of health workers worldwide pose a threat to attainment of the Sustainable Development Goals by 2030 and deepens already existing global health inequities. Rwanda and other low-resource countries face a critical shortage of health professionals, particularly nurses and midwives. This article describes the Human Resources for Health (HRH) Program in Rwanda, a collaboration between the Ministry of Health of Rwanda and a U.S. consortium of academic institutions. The ultimate goal of the HRH Program is to strengthen health service delivery and to achieve health equity for the poor. The aim of this article is to highlight the HRH nursing and midwifery contributions to capacity building in academic and clinical educational programs throughout Rwanda. International academic partnerships need to align with the priorities of the host country, integrate the strengths of available resources, and encourage a collaborative environment of cultural humility and self-awareness for all participants.

Genocide Rape Trauma Management: An Integrated Framework for Supporting Survivors.

During the 1994 Rwandan genocide, rape was widely used as a strategic weapon against Tutsi women. More than 20 years later, many of these women are still suffering devastating psychological, social, and physical effects of these experiences and remain in need of effective interventions that address their complex trauma. This article develops the theory of genocide rape trauma management as a conceptual framework for promoting the holistic health and recovery of female genocide rape survivors. A qualitative study using grounded theory explored the lived experiences of genocide rape survivors and led to the development of this model. The need for a contextually appropriate model is highlighted, with historical and current data regarding the Rwandan context and the experiences of genocide rape survivors. The research details the complex dynamics of emotional, physical, existential, and psychosocial sequelae related to genocide rape trauma, and how these interact with both local community and broader political attitudes toward survivors, as well as the serious interrelated economic challenges and limitations in current public health and welfare services. The research demonstrates the necessary elements of a holistic approach encompassing a synergistic combination of skilled psychological care, self-help strategies, collaborative support groups, community education, social reintegration, advocacy, accessible medical care, and economic empowerment. These interacting elements form the basis of the theory of genocide rape trauma management, offering an encompassing integrated framework that can be adapted to, and evaluated in, other similar contexts.

Issues and challenges of curriculum reform to competency-based curricula in Africa: A meta-synthesis.

Although in recent decades reforms to undergraduate nursing and midwifery education have increasingly been guided by the concept of competency-based curriculum in a drive to produce competent graduates in the African context, the topic remains poorly researched in-depth. The related issues and challenges need to be explored in the interest of evidence-based practice. This article stems from a systematic review of qualitative literature on the design and implementation of competency-based curriculum. Data was inductively analyzed using constant comparison. The two categories that emerged were: (i) the need for a paradigm shift to competency-based curriculum; and (ii) the associated issues and challenges, such as a shift from informative to transformative learning, lack or limited of involvement of key stakeholders in curriculum development, focus on hospital-oriented education, lack of preparation of educators, and inappropriate resources. While ongoing reform of nursing and midwifery education continues, much still needs to be done - in particular, extensive financial investment to increase the capacity of educators, mentors and infrastructure, and the development of collaborative frameworks between nursing and midwifery and higher educational councils.

Nephrology Nursing in Rwanda: Creating the Future Through Education and Organizational Partnership.

The Human Resources for Health Program was launched in Rwanda in 2012 as a sevenyear initiative to improve healthcare services and decrease overall dependence on foreign aid. In partnership between U.S. academic institutions and Rwandan education affiliates, nursing resources have become primarily centered on the design and implementation of Rwanda's first Masters of Science in Nursing (MScN) Program at the School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali. The nephrology track consists of seven students with a wealth of clinical and educational experience who will receive the training needed to become advanced, ethical, and capable leaders in the nephrology nursing field. Faculty member William Rosa collaborated with the American Nephrology Nurses Association (ANNA) to provide these students with the online community, continuing education, practice standards, and journal access required to be proficient as graduate nurses through the donations of virtual memberships and copies of necessary texts. This is the University of Rwanda's MScN Nephrology Track story.

The "treatment gap" in global mental health reconsidered: sociotherapy for collective trauma in Rwanda.

BACKGROUND: The "treatment gap" (TG) for mental disorders refers to the difference that exists between the number of people who need care and those who receive care. The concept is strongly promoted by the World Health Organization and widely used in the context of low- and middle-income countries. Although accepting the many demonstrable benefits that flow from this approach, it is important to critically reflect on the limitations of the concept of the TG and its implications for building capacity for mental health services in Rwanda. OBJECTIVE: The article highlights concerns that the evidence base for mental health interventions is not globally valid, and problematizes the preponderance of psychiatric approaches in international guidelines for mental health. Specifically, the risk of medicalization of social problems and the limited way in which "community" has been conceptualized in global mental health discourses are addressed. Rather than being used as a method for increasing economic efficiency (i.e., reducing healthcare costs), "community" should be promoted as a means of harnessing collective strengths and resources to help promote mental well-being. This may be particularly beneficial for contexts, like Rwanda, where community life has been disrupted by collective violence, and the resulting social isolation constitutes an important determinant of mental distress. CONCLUSIONS: Moving forward there is a need to consider alternative paradigms where individual distress is understood as a symptom of social distress, which extends beyond the more individually oriented TG paradigm. Sociotherapy, an intervention used in Rwanda over the past 10 years, is presented as an example of how communities of support can be built to promote mental health and psychosocial well-being.

The lived experience of genocide rape survivors in Rwanda.

PURPOSE: The purpose of this study was to explore the lived experience of women who were raped during the 1994 genocide in Rwanda. METHODS: A phenomenological approach was used and this study was carried out in Rwanda in three different locations. The 7 participants took part in three semi-structured, individual interviews which were audiotaped. RESULTS: Participants reported many themes unique to Rwandan women survivors of genocide. These themes included violation by perceived inferiors, loss of dignity and respect, loss of identity, social isolation, loss of hope for the future (i.e., HIV/AIDS), the ongoing torture of rape babies, and developing a sense of community. CONCLUSIONS: Rwandan women survivors of the 1994 genocide have lived through unimaginable suffering. Limited information is available regarding the experiences of these rape survivors and this information could create awareness and some understanding of what these women endured. CLINICAL RELEVANCE: This study can help nurses to understand the sequelae of war and rape and thus have needed information which can be used to offer assistance to women in these circumstances.