Mental health outcomes of offspring exposed to parental intimate partner violence in Rwanda.

BACKGROUND: Children who witness parental intimate partner violence (IPV) are more likely to develop mental health issues compared to those who do not witness such violence. OBJECTIVE: The main objective of this study is to assess the association between parental intimate partner violence and child mental health outcomes. METHODOLOGY: This cross-sectional study involved 548 participants divided into two groups: parents (N = 304) and offspring (N = 244). The participants were recruited from Mageragere Sector in the City of Kigali (urban), as well as Mbazi and Ruhashya sectors in Huye District (rural). To assess the difference about mental difficulties reported by the offspring, a Mann-Whitney U test was employed to compare the responses of parents and their children on mental health outcomes. Additionally, multiple linear regression analysis was conducted to explore the association between parental intimate partner violence (IPV) and the mental health outcomes of their offspring. RESULTS: The results highlighted significant levels of mental and emotional challenges in children, as reported by both parents and the children themselves. Depression and youth conduct problems were more prevalent among the children compared to their parents, whereas anxiety and irritability were more commonly reported by parents than by their children. Intimate partner violence showed to be a predictor of irritability and anxiety symptoms in offspring. In terms of irritability, depression, and youth conduct problems they were identified as predictors of anxiety symptoms. Particularly, anxiety and irritability were revealed to predict youth conduct problems. CONCLUSION: The study indicates that parental intimate partner violence (IPV) has an impact on the mental well-being of their offspring. Furthermore, it was observed that there is not only a correlation between IPV and poor mental health outcomes, but also a connection between different mental conditions, implying that children exposed to IPV are more prone to experiencing a range of mental issues. As a result, intervention programs should place emphasis on addressing the mental disorders of both parents and children.

Factors associated with neonatal sepsis among neonates admitted in Kibungo Referral Hospital, Rwanda.

More than one million neonatal deaths occur every year worldwide, of which 99% take place in low-income countries. In Rwanda, nearly 71% of neonatal deaths are preventable and among these, 10% are due to neonatal sepsis. Nevertheless, limited information exists on neonatal sepsis and its associated factors in Rwanda. The objectives of the study were to find prevalence and factors associated with neonatal sepsis among neonates admitted in Kibungo Referral Hospital, Ngoma District, Rwanda. We used a retrospective cross-sectional study design reviewing a subset of neonatal, maternal and laboratory records from Kibungo Hospital in 2017. Data were reviewed and collected from March to May, 2018. Logistic regression and odds ratios were calculated to identify the factors associated with neonatal sepsis at 95% CI, p < 0.05. Of the 972 total neonates' medical records from 2017, we randomly selected 422 of which 12.8% (n = 54) had neonatal sepsis. When blood cultures were positive, 62% grew Klebsiella pneumoniae. Among neonates with sepsis, 38 (70%) recovered while 16 (30%) died. Neonatal sepsis was strongly associated with neonatal age less than or equal to three days (aOR: 2.769, 95% CI 1.312-5.843; p = 0.008); and gestational age less than 37 weeks (aOR: 4.149; CI 1.1878-9.167; p ≤ 0.001). Increased use of blood cultures including sensitivity testing, routine surface cultures of the neonatology and maternity wards facilities, and systematic ward cleaning are all important approaches to prevent and treat neonatal infections in additional to regular neonatal sepsis evaluations.

Prevalence of depression, anxiety and stress and their risk and protective factors among secondary students in Rwanda during the first wave of COVID-19 pandemic.

INTRODUCTION: Compelling evidence shows that the COVID-19 pandemic has detrimental effects on the mental health of university students. However, little is known about the psychological distress experienced by students from high schools during the pandemic. This study, therefore, sought to examine the prevalence of depression, anxiety and stress and their associated factors among students from high schools in Rwanda. METHODS AND MATERIALS: A retrospective, cross-sectional study was conducted on 384 students randomly selected from high schools. Data were collected using standardized measures of mental disorders and their associated factors. Bivariate and multivariate analyses based on the odds ratio were used to indicate the associated factors of anxiety, depression, and stress. RESULTS: The results indicated that slightly above half of the participants (51%, n = 195) had clinically significant symptoms of depression, 30.3% (n = 116) had stress and 67.3% (n = 259) had anxiety. Our analyses identified several key risk factors associated with increased odds of these mental disorders. These include exposure to domestic violence, COVID-19 symptoms like cough and myalgia, eating twice per day, having one of the three mental disorders, gender, with females showing higher susceptibility, and direct contact with the people who positively tested covid-19. Conversely, protective factors such as heightened awareness about Covid-19, positive mental health, social support, eating three times, belonging to the third Ubudehe category, and a high resilience emerged as significant elements mitigating the risks of these mental health challenges within our sample. Intriguingly, religious affiliation emerged as a notable factor, with students affiliated with the Witness of Jehovah and Adventist denominations exhibited lower risks for depression and anxiety. CONCLUSION: Our findings highlighted a high prevalence of depression, anxiety, and stress among students from secondary schools. Interestingly, this study also revealed the associated risk and protective factors of depression, anxiety, and stress in Rwandan students in high schools. Therefore, mental health interventions targeting the impact of COVID-19 on students, as young people are needed.

Evidence of health system resilience in primary health care for preventing under-five mortality in Rwanda and Bangladesh: Lessons from an implementation study during the Millennium Development Goal period and the early period of COVID-19.

Background: The coronavirus disease 2019 (COVID-19) pandemic led to disruptions of health service delivery in many countries; some were more resilient in either limiting or rapidly responding to the disruption than others. We used mixed methods implementation research to understand factors and strategies associated with resiliency in Rwanda and Bangladesh, focussing on how evidence-based interventions targeting amenable under-five mortality that had been used during the Millennium Development Goal (MDG) period (2000-15) were maintained during the early period of COVID-19. Methods: We triangulated data from three sources - a desk review of available documents, existing quantitative data on evidence-based intervention coverage, and key informant interviews - to perform a comparative analysis using multiple case studies methodology, comparing contextual factors (barriers or facilitators), implementation strategies (existing from 2000-15, new, or adapted), and implementation outcomes across the two countries. We also analysed which health system resiliency capabilities were present in the two countries. Results: Both countries experienced many of the same facilitators for resiliency of evidence-based interventions for children under five, as well as new, pandemic-specific barriers during the early COVID-19 period (March to December 2020) that required targeted implementation strategies in response. Common facilitators included leadership and governance and a culture of accountability, while common barriers included movement restrictions, workload, and staff shortages. We saw a continuity of implementation strategies that had been associated with success in care delivery during the MDG period, including data use for monitoring and decision-making, as well as building on community health worker programmes for community-based health care delivery. New or adapted strategies used in responding to new barriers included the expanded use of digital platforms. We found implementation outcomes and strong resilience capabilities, including awareness and adaptiveness, which were related to pre-existing facilitators and implementation strategies (continued and new). Conclusions: The strategies and contextual factors Rwanda and Bangladesh leveraged to build 'everyday resilience' before COVID-19, i.e. during the MDG period, likely supported the maintained delivery of the evidence-based interventions targeting under-five mortality during the early stages of the pandemic. Expanding our understanding of pre-existing factors and strategies that contributed to resilience before and during the pandemic is important to support other countries' efforts to incorporate 'everyday resilience' into their health systems.

Stage at diagnosis and survival among adult patients with cancer in Rwanda: A population-based study.

There are marked disparities in cancer survival in low-income countries compared to high-income countries, yet population-based data in the first is largely lacking. In this study, data from the national cancer registry of Rwanda were examined for 542 patients diagnosed with eight of the most common cancers of adults stomach (C16), colorectum (C18-20), liver (C22), breast (female) (C50), cervix (C53), ovary (C56), prostate (C61), and non-Hodgkin lymphomas (C82-85) between 2014 and 2017. Subjects were randomly selected for active followed-up to calculate 1-, 3-, and 5-year observed and relative survival (RS) by cancer type and stage. Overall, 53.7% of cases had died within 5 years of diagnosis. Five-year RS varied by malignancy and ranged from 17.6% (95% confidence interval [CI]: 6.7%-32.6%) for liver cancer to 68% (CI: 51.6%-79.8%) for cancers of the prostate. Stage was assigned for 71.6% of patients (n = 388 of 542), with over half (58%) having advanced stage (III/IV) at diagnosis. For all except liver and ovary, stage was a strong predictor of survival; for example, three-year observed survival was 90.9% and 44.8% (p-value: .002) for early and advanced breast cancer, respectively. This study demonstrates that stage specific survival can be obtained from population based cancer registries in sub Saharan Africa, data that are invaluable for international benchmarking, and for local planning and evaluation of cancer control programs.

Depression symptoms and suicidal ideation among HIV infected Rwandans: the mediating and moderating effects of complicated grief and substance abuse.

BACKGROUND: People with HIV/AIDS (PWHA) have 7-36 times greater risk for completed suicide associated with depression symptoms compared to general population. However, no study has sufficiently analyzed the mediating or moderating variables of the relationship between depression and suicidal ideation in Rwanda. OBJECTIVES: This study aimed to examine how complicated grief mediates and substance abuse moderates the effects of depression symptoms on suicidal ideation. METHODS: Data were collected from a convenient sample of 140 participants (M-age = 38.79 years, SD = 10.218) receiving antiretroviral therapy (ART) at Remera Health Center in a cross-sectional study. Multiple linear regression and Sobel test were used to examine the relationships between depression symptoms, complicated grief, suicidal ideation, and substance abuse. RESULTS: The results indicated that 29% of the sample had clinically significant symptoms of depression and 18% had suicidal ideation. The interaction between substance abuse and depression symptoms (ß = .468, t = 8.02, p = 0.000) was a significant predictor, explaining the 55.7% of variance in suicidal ideation. Furthermore, the Sobel test demonstrated that complicated grief mediated the effects of depression symptoms (t = 4.67, SE = 0.0101, p ≤ 0.001) on suicidal ideation. CONCLUSION: The results suggest that depression symptoms are associated with an increased risk of suicidal ideation, and this risk significantly amplified in the presence of complicated grief and substance abuse. These findings highlight the importance of integrating mental health services, particularly those addressing depression, complicated grief, and substance abuse, into HIV care programs to mitigate the risk of suicidal ideation among PWHA.

Predictive Modelling of Postpartum Haemorrhage Using Early Risk Factors: A Comparative Analysis of Statistical and Machine Learning Models.

Postpartum haemorrhage (PPH) is a significant cause of maternal morbidity and mortality worldwide, particularly in low-resource settings. This study aimed to develop a predictive model for PPH using early risk factors and rank their importance in terms of predictive ability. The dataset was obtained from an observational case-control study in northern Rwanda. Various statistical models and machine learning techniques were evaluated, including logistic regression, logistic regression with elastic-net regularisation, Random Forests, Extremely Randomised Trees, and gradient-boosted trees with XGBoost. The Random Forest model, with an average sensitivity of 80.7%, specificity of 71.3%, and a misclassification rate of 12.19%, outperformed the other models, demonstrating its potential as a reliable tool for predicting PPH. The important predictors identified in this study were haemoglobin level during labour and maternal age. However, there were differences in PPH risk factor importance in different data partitions, highlighting the need for further investigation. These findings contribute to understanding PPH risk factors, highlight the importance of considering different data partitions and implementing cross-validation in predictive modelling, and emphasise the value of identifying the appropriate prediction model for the application. Effective PPH prediction models are essential for improving maternal health outcomes on a global scale. This study provides valuable insights for healthcare providers to develop predictive models for PPH to identify high-risk women and implement targeted interventions.

Prevalence of post-caesarean section surgical site infections in Rwanda: A systematic review and meta-analysis.

Caesarean section (C-section) is the most performed major surgery worldwide. About 15% of births are delivered through C-section in Rwanda. The post-caesarean surgical section is one of the most frequent complications that follow a C-section. The purpose of this systematic review and meta-analysis is to estimate the pooled prevalence of surgical site infections following caesarean section deliveries in Rwanda. A comprehensive search was conducted across PubMed/MEDLINE, Google Scholar, DOAJ, AJOL and the Cochrane Library to identify primary studies on post-caesarean surgical site infections in Rwanda. Studies meeting predetermined criteria were included, and their quality was assessed using the JBI Critical Appraisal Tools. Heterogeneity was evaluated using I2 statistics, while publication bias was examined via funnel plots and statistical tests. Pooled prevalence was calculated using Jamovi 2.3.28 software, with subgroup analysis conducted to identify sources of heterogeneity. Statistical significance was set at p < 0.05. From 139 articles initially searched from the databases, only 17 studies with 8, 082 individuals were finally included in the systematic review and meta-analysis. Using the random-effects model, the pooled estimate of post C-section SSIs prevalence in Rwanda was 6.85% (95% CI 5.2, 8.5). Subgroup analysis based on publication year, sample size, hospital and study design showed no much difference in SSI prevalence. The current systematic review and meta-analysis indicates that post-caesarean surgical site infections are significant in Rwanda. A collaborative effort is required to lower post-C-section SSIs and provide the best surgical care in the country.

Spatial disparity and associated factors of diarrhea among under-five children in Rwanda: a multilevel logistic regression analysis.

BACKGROUND: Diarrhea, defined as three or more loose stool per day, is a major cause of child mortality. Exploring its spatial distribution, prevalence, and influencing factors is crucial for public health decision and targeted interventions. This study aimed to investigate these aspects using 2019 Rwanda demographic health survey data. METHOD: A total 7,978 (weighted) under-five children were included in this study. Spatial clustering (hotspots areas) were mapped using ArcGIS and SaTscan software. A multilevel logistic regression model was fitted to assessed factors associated with diarrhea, reporting significance at p < 0.05 and a 95% confidence interval. RESULTS: diarrheal diseases in Rwanda showed a clustered spatial pattern (Moran's I = 0.126, p = 0.001), with the primary cluster in west and north provinces. Under-five diarrhea prevalence was 14.3% (95% CI: 13.55, 15.08). Factors increasing likelihood included maternal age 15-34 years, child age 7-24 months, while full immunization was protective (aOR = 0.74, 95% CI: 0.56, 0.98). CONCLUSION: Spatial clustering of diarrheal diseases is found in west and north provinces of Rwanda. Being born to a young mother, being a child aged 7-24 months, being fully immunized, being born to a low-educated mother and belonging to a community having low level education are factors associated with diarrheal diseases in Rwanda. Developing interventional plans based on identified clusters and approaching children based on their immunization status, maternal education and age could be cost-effective in reducing diarrheal diseases in Rwanda. Location based intervention could allow for the efficient allocation of resources by focusing on areas with higher prevalence and need.

Modeling the shared risks of malaria and anemia in Rwanda.

In sub-Saharan Africa, malaria and anemia contribute substantially to the high burden of morbidity and mortality among under-five children. In Rwanda, both diseases have remained public health challenge over the years in spite of the numerous intervention programs and policies put in place. This study aimed at understanding the geographical variations between the joint and specific risks of both diseases in the country while quantifying the effects of some socio-demographic and climatic factors. Using data extracted from Rwanda Demographic and Health Survey, a shared component model was conceived and inference was based on integrated nested Laplace approximation. The study findings revealed similar spatial patterns for the risk of malaria and the shared risks of both diseases, thus confirming the strong link between malaria and anaemia. The spatial patterns revealed that the risks for contracting both diseases are higher among children living in the districts of Rutsiro, Nyabihu, Rusizi, Ruhango, and Gisagara. The risks for both diseases are significantly associated with type of place of residence, sex of household head, ownership of bed net, wealth index and mother's educational attainment. Temperature and precipitation also have substantial association with both diseases. When developing malaria intervention programs and policies, it is important to take into account climatic and environmental variability in Rwanda. Also, potential intervention initiatives focusing on the lowest wealth index, children of uneducated mothers, and high risky regions need to be reinforced.

Factors associated with anaemia among pregnant women in Rwanda: an analysis of the Rwanda demographic and health survey of 2020.

BACKGROUND: Anaemia in pregnancy is associated with several adverse outcomes for mothers and newborns, as well as their families. In this study, we assessed the prevalence of anaemia and the associated factors among pregnant women in Rwanda. METHODS: Secondary data from the 2020 Rwanda Demographic and Health Survey (RDHS) was used. Multistage stratified sampling was used to select 435 pregnant women included in the study. Anaemia among pregnant women was defined as a haemoglobin value < 11 g/dL. Multivariable logistic regression was used to assess the associated factors with anaemia in pregnancy, using SPSS (version 26). RESULTS: Of the 435 pregnant women, 24.6% (95%CI: 21.1-29.3) were anaemic (1 in 4 pregnant women). Not working (AOR = 2.45; 95%CI: 1.14-5.26), being unmarried (AOR = 1.23; 95%CI: 1.24-3.57), low wealth index (AOR = 9.19; 95%CI: 1.64-51.56), having difficulty accessing a nearby health facility (AOR = 5.40; 95%CI: 2.21-13.23), and normal body mass index (AOR = 3.33; 95%CI: 1.46-7.59) were associated with higher odds of being anaemic. However, not taking iron supplements (AOR = 0.16; 95% CI: 0.04-0.67), having no exposure to television (AOR = 0.35; 95%CI: 0.14-0.91), being from the southern region (AOR = 0.14; 95% CI: 0.03-0.66), and low husband/partner's education (AOR = 0.08; 95% CI: 0.01-0.59) were associated with lower odds of being anaemic. CONCLUSIONS: The study findings indicate a high prevalence of anaemia in pregnancy, which was associated with several socio-demographics. There is a need for setting up mobile clinics and health facilities in hard-to-reach areas for easy accessibility to early anaemia screening services. Conducting mass screening for anaemia targeting pregnant women who are not working, the unmarried, and those with a low wealth index would also be beneficial. The intake of locally available iron rich foods and/ or bio-fortified foods is also recommended.

Intergenerational trauma transmission through family psychosocial factors in adult children of Rwandan survivors of the 1994 genocide against the Tutsi.

Thirty years after the 1994 genocide against the Tutsi in Rwanda, children of survivors are being increasingly documented to be at higher risk compared to their peers for adverse mental health outcomes. However, no studies in Rwanda have empirically explored family psychosocial factors underlying this intergenerational transmission of trauma. We investigated family psychosocial factors that could underlie this transmission in 251 adult Rwandan children of survivors (mean age = 23.31, SD = 2.40; 50.2% female) who completed a cross-sectional online survey. For participants with survivor mothers (n = 187), we found that both offspring-reported maternal trauma exposure and maternal PTSD were indirectly associated with children's PTSD via maternal trauma communication (specifically, nonverbal and guilt-inducing communication), and that maternal PTSD was indirectly associated with children's PTSD, anxiety, and depression symptoms through family communication styles. For participants with survivor fathers (n = 170), we found that paternal PTSD symptoms were indirectly associated with children's anxiety and depression symptoms via paternal parenting styles (specifically, abusive and indifferent parenting). Although replication is needed in longitudinal research with parent-child dyads, these results reaffirm the importance of looking at mass trauma in a family context and suggest that intergenerational trauma interventions should focus on addressing family communication, trauma communication, and parenting.

The Vicious Worm education tool improves the knowledge of community health workers on Taenia solium cysticercosis in Rwanda.

The pork tapeworm Taenia solium causes human taeniasis and cysticercosis when ingested as viable cysts and eggs, respectively. Despite its high health burden in low-income countries, knowledge of the parasite in endemic areas such as Rwanda is often limited. Here, we assess whether The Vicious Worm education software can increase knowledge in endemic areas of Rwanda. A cross-sectional mixed-methods study was conducted to evaluate knowledge about T. solium among community health workers trained using the Vicious Worm education software. Knowledge was assessed before, immediately after, and four weeks after the training. The health workers perceptions of the software were analysed thematically. A total of 207 community health workers were recruited from Nyamagabe district in Southern Province, Rwanda. Participants were composed of males (33.5%) and females (66.5%), aged between 22 and 68 years, and most (71%) had only completed primary education. Knowledge of cysticercosis at baseline was low, particularly knowledge of human cysticercosis and neurocysticercosis. The overall knowledge score increased significantly after training and was maintained four weeks after the training. Overall, insufficient knowledge was associated with neurocysticercosis-related questions, which after the training, remained relatively lower compared to questions of other categories. Participants reported the software to be user-friendly and educational. Digital illiteracy and the lack of smartphones were among the critical challenges highlighted in responses. This study has shown gaps in knowledge regarding T. solium infections within rural Rwanda, particularly neurocysticercosis. Health education using the Vicious Worm education software should be considered in integrated control programs.

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.

Determinants of coexistence of undernutrition and anemia among under-five children in Rwanda; evidence from 2019/20 demographic health survey: Application of bivariate binary logistic regression model.

BACKGROUND: Undernutrition and anemia are significant public health issues among under-5 children, with potential long-term consequences for growth, development, and overall health. Thus, this study aims to conduct a bivariate binary logistic regression model by accounting for the possible dependency of childhood undernutrition and anemia. METHODS: The data came from the DHS program's measurement. A total of 3,206 under-five children were involved in this study. A single composite index measure was calculated for stunting, wasting, and underweight using principal component analysis. A bivariate binary logistic regression model is used to assess the association between undernutrition and anemia given the effect of other predictors. RESULTS: Among 3,206 under-five children considered in this study, 1482 (46.2%) and 658 (20.5%) children were agonized by anemia and undernutrition, respectively. In bivariate binary logistic regression model; Urban children [AOR = 0.751, 96% CI: 0.573-0.984; AOR = 0.663, 95% CI: 0.456-0.995] and anemic mothers [AOR = 1.160, 95% CI: 1.104-1.218; AOR = 1.663, 95% CI: 1.242-2.225] were significantly associated with both childhood anemia and undernutrition, respectively. Improved water sources [AOR = 0.681, 95% CI: 0.446-0.996], average-sized children [AOR = 0.567, 95% CI: 0.462-0.696], and diarrhea [AOR = 1.134, 95% CI: 1.120-2.792] were significantly associated with childhood anemia. Large-sized children [AOR = 0.882, 95% CI: 0.791-0.853] and those with fever [AOR = 1.152, 95% CI: 1.312-2.981] were significantly associated with under-five children's undernutrition. CONCLUSION: The prevalence of both undernutrition and anemia among under-five-year-old children was high in Rwanda. The following determinants are statistically associated with both childhood undernutrition and anemia: place of residence; source of drinking water; maternal anemia; being a twin; birth size of children; diarrhea; fever; and child age. Anemia and nutritional deficiencies must be treated concurrently under one program, with evidence-based policies aimed at vulnerable populations.

Stage at diagnosis and survival by stage for the leading childhood cancers in Rwanda.

BACKGROUND: The lack of accurate population-based information on childhood cancer stage and survival in low-income countries is a barrier to improving childhood cancer outcomes. METHODS: In this study, data from the Rwanda National Cancer Registry (RNCR) were examined for children aged 0-14 diagnosed in 2013-2017 for the eight most commonly occurring childhood cancers: acute lymphoblastic leukaemia, Hodgkin lymphoma (HL), Burkitt lymphoma (BL), non-Hodgkin lymphoma excluding BL, retinoblastoma, Wilms tumour, osteosarcoma and rhabdomyosarcoma. Utilising the Toronto Childhood Cancer Stage Guidelines Tier 1, the study assigned stage at diagnosis to all, except HL, and conducted active follow-ups to calculate 1-, 3- and 5-year observed and relative survival by cancer type and stage at diagnosis. RESULTS: The cohort comprised 412 children, of whom 49% (n = 202) died within 5 years of diagnosis. Five-year survival ranged from 28% (95% confidence interval [CI]: 12.5%-45.6%) for BL to 68% (CI: 55%-78%) for retinoblastoma. For the cancers for which staging was carried out, it was assigned for 83% patients (n = 301 of 362), with over half (58%) having limited or localised stage at diagnosis. Stage was a strong predictor of survival; for example, 3-year survival was 70% (95% CI: 45.1%-85.3%) and 11.8% (2.0%-31.2%) for limited and advanced non-HL, respectively (p < .001). CONCLUSION: This study is only the second to report on stage distribution and stage-specific survival for childhood cancers in sub-Saharan Africa. It demonstrates the feasibility of the Toronto Stage Guidelines in a low-resource setting, and highlights the value of population-based cancer registries in aiding our understanding of the poor outcomes experienced by this population.

Challenges to epilepsy management in Rwandan women living with epilepsy.

BACKGROUND AND PURPOSE: In Rwanda, epilepsy prevalence ranges between 29‰ and 49‰. Many women living with epilepsy (WwE) are of childbearing age. Epilepsy characteristics and management, contraception, pregnancy, puerperium and stigma in WwE presenting at the neurology clinic of Ndera, Rwanda, were investigated. METHODS: This prospective cross-sectional study investigated demographics, epilepsy characteristics, treatment, contraception, folic acid use, pregnancy, puerperium and stigma in WwE aged ≥18 years. Subgroups were analysed by status of any pregnancy and time of epilepsy diagnosis relative to pregnancy, with significant differences expected. RESULTS: During December 2020 and January 2021, a hundred WwE were enrolled (range 18-67 years). Fifty-two women had never been pregnant, 39 women had epilepsy onset before pregnancy and nine were diagnosed after pregnancy. No significant differences in age, marital status or occupation were observed. Contraception was used by 27%, of whom 50% were taking enzyme-inducing anti-epileptic medication. Valproate was used by 46% of WwE of reproductive age. Thirty-nine women with epilepsy onset before pregnancy reported 91 pregnancies, with 14% spontaneous abortions. None used folic acid before conception, and 59% only during pregnancy. Five of 78 newborns were preterm. No offspring had major congenital malformations. Nearly 25% of WwE were not compliant with their anti-epileptic medication schedule during pregnancy or breastfeeding. Internalized stigma was observed in more than 60%. Up to 25% had been discriminated against at school or work. CONCLUSION: A comprehensive strategy considering the reproductive health and societal challenges of WwE is needed to drive optimal epilepsy management, reproductive health outcomes and societal inclusion.

Hepatitis C Elimination in Rwanda: Progress, Feasibility, and Economic Evaluation.

OBJECTIVES: In 2018, Rwanda launched a national program to eliminate the hepatitis C virus (HCV). We aim to assess the impact of the program to date and identify strategies to achieve the World Health Organization's HCV elimination goals by 2030. METHODS: We developed a microsimulation model to simulate Rwanda's HCV epidemic from 2015 through 2050 and evaluated temporal trends in HCV infection, prevalence, mortality, and the total cost of care for scenarios that could achieve HCV elimination by 2030. RESULTS: Between 2018 and 2022, over 7 million people were screened for HCV, and 60 000 were treated. The study projected that Rwanda could achieve HCV elimination as early as 2027. A feasible strategy of an annual screening rate of 15% and a treatment rate of 100% would achieve all World Health Organization elimination goals by 2028, requiring screening an additional 4 million people and treating 23 900 patients by 2030. The elimination strategy costs $25 million for screening and diagnosis and $21 million for treatment from 2015 to 2050. The national program would avert 4900 hepatocellular carcinoma cases and 6700 HCV-related deaths and save the health system $25.33 million from 2015 to 2050. CONCLUSIONS: Rwanda is poised to become one of the first countries in the world to eliminate HCV. Rwanda's program serves as a blueprint for other countries in the African region. By rapid screening and treatment scale-up (eg, by leveraging HIV platforms) and by drug price negotiations, HCV elimination is not only feasible but can be cost-saving in low-income settings.

Understanding differential reductions in undernutrition among districts in Rwanda through the perspectives of mid-level and community actors on policy commitment and policy coherence.

Understanding the drivers of improvements in child undernutrition at only the national level can mask subnational differences. This paper aimed to understand the contributions of factors in the enabling environment to observed differences in stunting reduction between districts in Rwanda. In 2017, we conducted 58 semi-structured interviews with mid-level actors (n = 38) and frontline workers (n = 20) implementing Rwanda's multi-sectoral nutrition policy in five districts in which stunting decreased (reduced districts) and five where it increased or stagnated (non-reduced districts) based on Rwanda's 2010 and 2014/15 Demographic and Health Surveys. Mid-level actors are government officials and service providers at the subnational level who represent the frontline of government policy. Interviews focused on political commitment to and policy coherence in nutrition, and contributors to nutrition changes. Responses were coded to capture themes on the changes and challenges of these topics and compared between reduced and non-reduced districts. Descriptive statistics described district characteristics. Political commitment to nutrition was high in both reduced and non-reduced districts. Respondents from reduced districts were more likely to define commitment to nutrition as an optimal implementation of policy, whereas those from non-reduced districts focused more on financial commitment. Regarding coherence, respondents from reduced compared to non-reduced districts were more likely to report the optimal implementation of multi-sectoral nutrition planning meetings, using data to assess plans and progress in nutrition outcomes and integration of nutrition into the agriculture sector. In contrast, respondents from non-reduced districts more often reported challenges in their relationships with national-level stakeholders and nutrition and/or monitoring and evaluation capacities. Enhancing the integration of nutrition in different sectors and improving mid-level actors' capacity to plan and advocate for nutrition programming may contribute to reductions in stunting.