Vincent Kalumire Cubaka

Purpose: Late-stage diagnoses drive high rates of cervical and breast cancer mortality in low- and middle-income countries (LMICs) where early detection efforts are typically small-scale. Rwanda's government-funded Women's Cancer Early Detection Program (WCEDP) integrates breast cancer early detection and cervical cancer screening and is being scaled nationally. We aimed to understand barriers and facilitators of WCEDP scale-up to inform program optimization and provide lessons for other LMICs. Methods: We conducted 23 in-depth interviews with clinicians, health facility leaders, nongovernmental organization (NGO) staff, and policymakers. A codebook was collaboratively developed using a combined inductive and deductive approach; all transcripts were dual-coded. The Exploration, Preparation, Implementation, and Sustainment (EPIS) framework served as a guiding theoretical framework. Results: Outer context: WCEDP facilitators include strong government engagement, national cancer control plans, and community acceptance. Barriers include low community awareness and insufficient resources dedicated to the program. Inner context: Rwanda's decentralized health care system and community health workers facilitated WCEDP scale-up. Nonetheless, workforce shortages, limited health facility leadership engagement and accountability, and clinicians' unfamiliarity with electronic health records (EHRs) were challenges. Innovation factors: The WCEDP-specific EHR was considered a strength. However, participants identified the need for training, technical assistance, ongoing quality monitoring, and adaptation to effectively use the EHR to improve care delivery and link patients to follow-up. Bridging factors: NGOs play a key role in WCEDP implementation. However, participants reported a need for improved coordination of different stakeholders. Phases of implementation: Identified facilitators and barriers provided lessons relevant to all EPIS phases (Exploration, Preparation, Implementation, and Sustainment). Conclusion: This study contributes to the limited literature examining scale-up of cancer programs in resource-constrained settings and informs strategies to optimize women's cancer early detection at scale in Rwanda and other LMICs.

Background: Mobile health (mHealth) apps are increasingly leveraged to support community health workers (CHWs) in delivering high-quality care, particularly in low- and middle-income countries. However, despite the proliferation of mHealth tools, few have been implemented at scale, partly due to limited attention to usability and acceptability among end users. In sub-Saharan Africa, mHealth tools designed for CHWs often lack systematic evaluation using validated instruments tailored to local contexts. Without such assessments, it is difficult to ensure that these tools can be integrated effectively into CHW workflows and scaled sustainably. Objective: This study aimed to adapt and validate existing mHealth usability and acceptability assessment tools to be contextually appropriate for CHWs in Rwanda. Specifically, we sought to ensure contextual appropriateness for CHWs supporting postoperative home follow-up for women after cesarean delivery. The resulting tool was designed for use in an implementation study of a novel CHW-led mHealth app. Methods: This study was conducted in the Kirehe district, Rwanda, from October 2022 to March 2023. We adapted 2 established tools—the mHealth App Usability Questionnaire and selected items from the Practitioner Opinion (Acceptability) Scale—and added new items that reflect core functions of the CHW-focused mHealth app. All items were translated into Kinyarwanda and simplified to align with CHWs’ educational levels. We conducted a three-stage validation that consisted of (1) content validity testing with 8 local and international experts using a recommended content validity index threshold of >0.78; (2) face validity testing with 10 CHWs using a recommended face validity index threshold of ≥0.60; and (3) reliability testing using responses from 30 CHWs, with a Cronbach α coefficient of ≥0.70 indicating acceptable internal consistency. Results: Of the 25 items assessed, 22 (88%) achieved a content validity index score of >0.78 for both clarity and relevance. The face validity index across all 22 items was 0.991, indicating strong comprehensibility and relevance to CHWs. Internal consistency was high: the Cronbach α was 0.86 for the mHealth App Usability Questionnaire items, 0.73 for the Practitioner Opinion (Acceptability) Scale items, and 0.87 for the newly developed questions. The final tool—named the Community Health Worker mHealth Usability and Acceptability Assessment Tool—included 22 items with strong content validity, face validity, and internal reliability. Conclusions: This study presents a rigorously adapted and validated tool for assessing mHealth usability and acceptability among CHWs in Rwanda. The Community Health Worker mHealth Usability and Acceptability Assessment Tool can guide future evaluations of mHealth interventions in similar contexts and serve as a model for localizing mHealth assessment tools in low- and middle-income country settings to ensure fit-for-purpose implementation.

Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, most commonly in the fallopian tube. While rare, ectopic pregnancies can also occur in atypical locations such as the ovary, cervix, abdominal cavity, or broad ligament, often posing significant diagnostic and therapeutic challenges. We report a highly unusual case of ectopic pregnancy implanted in the left labium majus, a site not previously documented in the literature. A 20‐year‐old woman presented with abdominal pain, vulvar swelling, and amenorrhea of approximately 4 months. Initial imaging and clinical evaluation did not reveal the ectopic implantation. Diagnosis was made intraoperatively during marsupialization of the vulvar swelling, which revealed a macerated fetus within the left labium majus. This case highlights the importance of maintaining a high index of suspicion for rare ectopic pregnancy sites in patients presenting with unexplained vulvar symptoms and a positive pregnancy test—particularly when imaging is inconclusive. It underscores the critical role of prompt surgical exploration in preventing life‐threatening complications and contributes to expanding the clinical spectrum of ectopic pregnancy presentations.

BACKGROUND Mobile health (mHealth) apps are increasingly leveraged to support community health workers (CHWs) in delivering high-quality care, particularly in low- and middle-income countries. However, despite the proliferation of mHealth tools, few have been implemented at scale, partly due to limited attention to usability and acceptability among end users. In sub-Saharan Africa, mHealth tools designed for CHWs often lack systematic evaluation using validated instruments tailored to local contexts. Without such assessments, it is difficult to ensure that these tools can be integrated effectively into CHW workflows and scaled sustainably. OBJECTIVE This study aimed to adapt and validate existing mHealth usability and acceptability assessment tools to be contextually appropriate for CHWs in Rwanda. Specifically, we sought to ensure contextual appropriateness for CHWs supporting postoperative home follow-up for women after cesarean delivery. The resulting tool was designed for use in an implementation study of a novel CHW-led mHealth app. METHODS This study was conducted in the Kirehe district, Rwanda, from October 2022 to March 2023. We adapted 2 established tools—the mHealth App Usability Questionnaire and selected items from the Practitioner Opinion (Acceptability) Scale—and added new items that reflect core functions of the CHW-focused mHealth app. All items were translated into Kinyarwanda and simplified to align with CHWs’ educational levels. We conducted a three-stage validation that consisted of (1) content validity testing with 8 local and international experts using a recommended content validity index threshold of >0.78; (2) face validity testing with 10 CHWs using a recommended face validity index threshold of ≥0.60; and (3) reliability testing using responses from 30 CHWs, with a Cronbach α coefficient of ≥0.70 indicating acceptable internal consistency. RESULTS Of the 25 items assessed, 22 (88%) achieved a content validity index score of >0.78 for both clarity and relevance. The face validity index across all 22 items was 0.991, indicating strong comprehensibility and relevance to CHWs. Internal consistency was high: the Cronbach α was 0.86 for the mHealth App Usability Questionnaire items, 0.73 for the Practitioner Opinion (Acceptability) Scale items, and 0.87 for the newly developed questions. The final tool—named the Community Health Worker mHealth Usability and Acceptability Assessment Tool—included 22 items with strong content validity, face validity, and internal reliability. CONCLUSIONS This study presents a rigorously adapted and validated tool for assessing mHealth usability and acceptability among CHWs in Rwanda. The Community Health Worker mHealth Usability and Acceptability Assessment Tool can guide future evaluations of mHealth interventions in similar contexts and serve as a model for localizing mHealth assessment tools in low- and middle-income country settings to ensure fit-for-purpose implementation.

The COVID-19 pandemic has disrupted health services worldwide, which may have led to increased mortality and secondary disease outbreaks. Disruptions vary by patient population, geographic area, an...

During the COVID-19 pandemic in Rwanda, Partners In Health Inshuti Mu Buzima collaborated with the Butaro Cancer Center of Excellence (BCCOE) to mitigate disruptions to cancer care by providing patients with free transportation to treatment sites and medication delivery at patients’ local health facilities. We assessed the relationship between facilitated access to care and self-reported wellbeing outcomes. This cross-sectional telephone survey included cancer patients enrolled at BCCOE in March 2020. We used linear regression to compare six dimensions of quality of life (EORTC QLQ-C30), depression (PHQ-9), anxiety (GAD-7), and financial toxicity (COST) among patients who did and did not receive facilitated access to care. We also assessed access to cancer care and whether patient wellbeing and its association with facilitated access to care differed by socioeconomic status. Of 214 respondents, 34.6% received facilitated access to care. Facilitated patients were more likely to have breast cancer and be on chemotherapy. Facilitation was significantly associated with more frequent in-person clinical encounters, improved perceived quality of cancer care, and reduced transportation-related barriers. Facilitated patients had significantly better global health status (β = 9.14, 95% CI: 2.3, 16.0, p <0.01) and less financial toxicity (β = 2.62, 95% CI: 0.2,5.0, p = 0.03). However, over half of patients reported missing or delaying appointment. Patient wellbeing was low overall and differed by patient socioeconomic status, with poor patients consistently showing worse outcomes. Socioeconomic status did not modify the association between facilitated access to care and wellbeing indicators. Further, facilitation did not lead to equitable wellbeing outcomes between richer and poorer patients. Facilitated access to care during COVID-19 pandemic was associated with some improvements in access to cancer care and patient wellbeing. However, cancer patients still experienced substantial disruptions to care and reported low overall levels of wellbeing, with socioeconomic disparities persisting despite facilitated access to care. Implementing more robust, equity-minded facilitation and better patient outreach programs during health emergencies may promote better care and strengthen patient care overall and effect better patients’ outcomes.

Introduction: To combat poor clinical outcomes among HIV-positive youth, Partners In Health/Inshuti Mu Buzima (PIH/IMB) implemented Adolescent Support Groups (ASGs), which combined peer support and group-based economic incentives to promote treatment adherence, economic empowerment, and viral suppression. This study assesses the association between ASG membership and clinical outcomes among HIV-positive youth living in rural Rwanda. Methods: We constructed a retrospective cohort using PIH/IMB’s electronic medical record (EMR) system. ASG members were matched to control youth within strata defined by health facility, year of birth, and whether the patient had enrolled in HIV services as a pediatric patient, as a PMTCT mother, or through another route. Our 12-month outcomes of interest were a) death-free retention in care, b) death-free retention with active follow-up, c) ≥80% adherence to appointment keeping, and d) viral load suppression (<20 copies/ml). We used generalized linear mixed models to estimate odds ratios for the association between ASG participation and each outcome. To mitigate possible unmeasured confounding, we additionally included participant data from the previous year and conducted a difference-in-difference analysis for each outcome to assess whether ASG members experienced greater changes compared to control youth over a similar period. Results: Two-hundred sixty ASG members were identified in the EMR and matched to 209 control youth for analysis. After 12 months of follow-up, ASG members had similar outcomes to the control youth in terms of death-free retention (93% vs. 94%), death-free retention with active follow-up (79% vs. 78%), ≥80% adherence to appointment keeping (42% vs. 43%), and viral suppression (48% vs. 51%). We did not observe any significant associations between ASG participation and clinical outcomes in crude or adjusted models, nor did ASG members experience greater improvements than control youth in our difference-in-difference analysis. Conclusions: The ASG program did not improve retention, appointment adherence, or viral suppression among HIV positive youth in rural Rwanda. Challenges implementing the intervention as designed underscore the importance of incorporating implementation strategies and youth perspectives in program design. This population remains vulnerable to poor clinical outcomes, and additional research is needed to better serve youth living with HIV.

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.

Background: Family Medicine is a novel discipline in many countries, where the motivation for training and value added to communities is not well-described. Our purpose was to understand the reason behind the choice of Family Medicine as a profession, the impact of Family Medicine on communities, and Family Medicine’s characterizing qualities, as perceived by family doctors around the world.Methods: One-question video interviews were conducted using an appreciative inquiry approach, with volunteer participants at the 2016 World Organization of Family Doctors conference in Rio de Janeiro. Qualitative data analysis applied the thematic, framework method.Results: 135 family doctors from 55 countries participated in this study. Three overarching themes emerged: 1) key attributes of Family Medicine, 2) core Family Medicine values and 3) shared traits of family doctors. Family Medicine attributes and values were the key expressed motivators to join Family Medicine as a profession and were also among expressed factors that contributed to the impact of Family Medicine globally. Major sub-themes included the principles of comprehensive care, holistic care, continuity of care, patient centeredness, and the patient-provider relationship. Participants emphasized the importance of universal care, human rights, social justice and health equity.Conclusion: Family doctors around the world shared stories about their profession, presenting a heterogeneous picture of global Family Medicine unified by its attributes and values. These stories may inspire and serve as positive examples for Family Medicine programs, prospective students, advocates and other stakeholders.