Janna M. Schurer

Taenia solium is a zoonotic cestode and the causative agent of human taeniasis/cysticercosis and porcine cysticercosis. The burden in Rwanda is significant, including death and disability in people and income losses across the pork sector. Despite widespread recognition on the need for multi-sectoral and inclusive T. solium control programming, little is known about water, sanitation and hygiene (WASH) access and gendered disease exposure among rural smallholders involved in the formal and informal pork sectors. This study aimed to characterize gender roles and WASH access in the Nyamagabe District (Southern Province) pork value chain (PVC) to better inform future interventions for disrupting T. solium transmission. We conducted Focus Group Discussions with 23 men and 21 women across five nodes of the PVC (farmers, animal health workers, butchers, vendors, consumers) and interviewed six key informants. Audio-recordings were transcribed verbatim, translated into English and coded as part of inductive thematic analysis. PVC participants identified numerous biosecurity gaps in the Nyamagabe PVC, such as free-range pig production, re-use of human waste, lack of prevention services (deworming, vaccination), informal slaughter, and consumption of infected and/or undercooked pork. Traditional gender roles were prevalent, with women managing domestic roles related to pig husbandry and men managing roles related to building pens, buying/selling pigs and slaughtering/butchering. Water and sanitation facilities were frequently inadequate, causing serious lapses in human and pig hygiene. Participants identified poverty as a major barrier for implementing T. solium control but demonstrated enthusiasm for receiving information and resources to support this goal. Altogether, these findings support the need for One Health programming to reduce the burden of T. solium and other zoonotic diseases in people and pigs in Rwanda. Gendered norms among rural smallholders indicated a need for gender transformative information campaigns targeting specific recipients along the PVC nodes.

Podoconiosis is a disabling neglected tropical disease (NTD) caused by prolonged occupational exposure to alkaline red clay soil, disproportionately affecting female farmers in Rwanda. Although preventable through the consistent use of protective footwear, such as farming boots, high costs and limited availability at local markets impede rural farmers’ access to appropriate footwear. Among female farmers, gender norms and cultural expectations further constrain their ability to access and wear farming boots. This qualitative community-based participatory project aimed to test a women-centered farming boot, co-designed by participants and the research team, to address previously identified barriers to protective footwear access among rural Rwandan farmers. Boots were distributed for testing, to male and female farmers, in four villages with the highest podoconiosis prevalence across Rwanda. This was paired with education campaigns and other informational materials. Sixteen audio-recorded focus group discussions were subsequently conducted to explore farmers’ experiences with the boots. Farmers reported that receiving the footwear encouraged a more consistent use of farming boots, with female participants expressing feelings of pride and an emerging sense of empowerment associated with owning and wearing the boots. While community reactions to the boots varied, most female farmers noted that restrictive gender norms and expectations related to boot wearing persist but do not deter them from wearing the boots. Findings reiterate the importance of gender-sensitive, culturally tailored, and locally driven solutions in preventing podoconiosis and other skin NTDs. Future podoconiosis eradication strategies should strive to prioritize equitable access to protective footwear and address underlying social norms that limit women’s access to preventive tools.

Podoconiosis is a preventable Neglected Tropical Disease (NTD) that results in significant lower limb swelling and chronic disability. Its management can be done at home by regularly washing feet with clean water and soap and using protective footwear. This study aimed to explore podoconiosis patients’ experiences with access to water, sanitation, and hygiene (WASH) and to identify barriers and facilitators of home-based management (HBM). In this qualitative phenomenological study, participants were recruited following a screening conducted in Butaro Sector (Rwanda) to identify individuals with lower limb lymphedema. Randomly selected individuals underwent a clinical assessment, and only those confirmed to have podoconiosis were invited for an interview. In-depth interviews, supplemented by observation and photographs, were conducted. Transcripts were inductively coded using Dedoose (version 9.0.80) and analyzed through thematic analysis. Overall, 26 interviews were conducted across all five cells of Butaro Sector. Poverty and physical discomfort were major barriers in accessing WASH and HBM essentials, with many relying on family or neighbors for support. Shame, laughter, and discrimination from community members further hindered access to WASH. However, some participants found a financial solution in selling animal and household waste. Moreover, participants demonstrated little or no knowledge about podoconiosis which influenced their treatment choices. Many attributed the disease to witchcraft, blood infection, or God’s will. Common care choices included traditional healers, self-care, or health centers. These findings demonstrate the need to integrate community education into podoconiosis management programs to address misconceptions and stigma while promoting income-generating activities to ensure consistent access to HBM essentials.

The Government of Rwanda recently instated a minimum menstrual hygiene management (MHM) package for all schools; however, coverage is not universal, and there remains little information on the availability or financial burden of MHM resources in rural and remote areas. This study sought to describe Rwandese secondary school girls’ perceptions and practices of MHM, their financial costs, and their access to MHM related infrastructure and products. A mixed-methods survey was conducted in three phases, namely (1) a quantitative questionnaire (2) a qualitative ‘Jar Voices’ activity, and (3) an observational Water, Sanitation and hygiene (WASH) checklist. One Lower Secondary School (LSS) of each type (private, public and government-aided) was randomly selected from each of Rwanda’s five provinces, and all LSS2 and LSS3 girls who reached menarche were invited to participate. Overall, 1,117 girls participated, including 351 (31.4%) from public schools, 543 (48.6%) from government aided schools and 223 (20.0%) from private schools. Only 35.7% of the girls correctly identified the origin of menstruation. The main source of information on menstruation was mothers. Most girls (82.5%) used single-use sanitary pads, and a small proportion (14.6%) relied on reusable cloth pads. The most identified barriers to accessing sanitary products were financial barriers. The average cost of menstrual products per cycle varied between RWF 3,100 in private schools, to RWF 4,000/4,300 in public/government-aided schools, and were covered mainly by parents. Most schools had gender-sensitive sanitation facilities, mainly pit latrines (86.7%), but only 53.3%, 33.33% and 20% provided water, soap and MHM commodities respectively. The results underscored the need for continuous menstrual education aimed at both girls and parents, and capitalizing on low-cost initiatives that can improve access to sanitary pads and WASH/sanitary facilities in schools.

Background: Snakebite envenoming (SBE) is a potentially life-threatening event that can lead to severe physical, mental, and economic hardships, particularly in under-resourced regions like sub-Saharan Africa. In Rwanda, there have been no epidemiological assessments of SBE to guide the Ministry of Health in its efforts to reduce the burden. This study had two main objectives: first, to estimate the incidence of snakebites across districts, and second, to describe formal versus informal healthcare seeking behaviors among snakebite victims in Eastern Province, Rwanda in 2020. Methodology: This cross-sectional study utilized a cluster sampling approach, involving Community Health Workers (CHWs) who recorded snakebite cases across seven districts. The descriptive analysis considered sampling weights, and healthcare seeking behavior was assessed based on the type of care sought as the first point of treatment. Findings: The study surveyed 390,546 individuals across 763 villages and estimated a provincial annual incidence rate of 4.3 cases per 1,000 individuals. Incidence estimates ranged from 1.1 cases per 1,000 in Nyagatare to 9.1 cases per 1,000 individuals in Bugesera and Ngoma districts. Among the 2,545 cases recorded by CHWs, three resulted in deaths. Regarding healthcare-seeking behavior, 13% of snakebite victims (143 out of 1,098) initially consulted formal care providers (CHWs, health post/center, or hospital), while 87% sought informal care (family/friends, pharmacist, or traditional healer). Approximately half of the victims (583, 53.1%) reported severe symptoms. Unsafe practices included skin cutting/burning, tourniquet application, use of black stones, and venom extraction; only 24 cases (2.2%) received anti-venom. Conclusions: This large-scale community-based assessment highlights variations in snakebite incidence between districts and confirms frequent involvement of traditional healers in management. Improving access to anti-venom and community education on the risks of ineffective practices, along with timely use of formal healthcare, are crucial. Collaboration between healthcare providers, traditional healers, community leaders, and policymakers is essential to implement targeted interventions for enhancing snakebite prevention and management strategies.

Podoconiosis is a debilitating neglected tropical disease (NTD) that is possibly caused by prolonged exposure to irritant alkaline clay soil. It is endemic to East Africa and disproportionately affects rural female farmers. The condition can be prevented through foot hygiene and regular wearing of protective shoes. In Rwanda, there is limited information on the factors impacting rural female farmers’ access to and utilization of boots while farming. Therefore, this community-based participatory study was conducted to explore the cultural, economic, and ergonomic factors affecting rural farmers’ use of protective footwear. Sixteen audio-recorded focus group discussions were conducted with female and male farmers in four villages with the highest podoconiosis prevalence across four provinces of Rwanda. Transcripts were coded inductively using Dedoose (version 9.0.86) and analyzed through thematic content analysis. Participants expressed that wearing shoes protects against diseases and injuries but ability to afford a pair of protective footwear was a major barrier to accessing and wearing them. There were differences in women and men’s shoe-wearing behaviors while farming, largely driven by the fact that women who wear boots face rumors and backlash. Findings highlight barriers hindering effective podoconiosis prevention among rural female farmers in Rwanda. Opportunities exist to strengthen podoconiosis and NTD prevention programs, through the integration of gender into existing community-based interventions and the inclusion of local communities into the co-designing of contextualized interventions.

Background: Podoconiosis is a progressive and debilitating form of tropical lymphoedema endemic to Rwanda. Although the physical and psychological consequences are well known, few studies have evaluated the financial burden of podoconiosis. Methods: This cross-sectional, quantitative study aimed to characterize direct treatment costs and impacts on annual earnings among individuals living with podoconiosis. Participants from two highly endemic districts were invited to complete a survey focused on health-seeking history, insurance status, out-of-pocket costs and income changes. Direct treatment costs included medical expenditures (consultation, diagnostics, medication) and non-medical expenditures (food, transportation, accommodation). Results: Overall, 226 adults (≥18 y of age) diagnosed with podoconiosis participated. Most had access to community-based health insurance (91.6%) but were unable to work (71.7%). Respondents sought care from health centres/posts (61.9%), hospitals (25.1%), traditional healers (5.8%) and/or community health workers (4.0%). On average, study participants paid US$32.50 (range US$0–779.23) annually, or 11.7% of their household salary, on podoconiosis treatments. Conclusions: This study demonstrates the significant financial burden of podoconiosis on individuals and their communities. Increased attention on integrating podoconiosis management into primary care systems and testing cost-effective solutions is needed to protect those who are most vulnerable.

Snakebite envenomation (SBE) is endemic to sub-Saharan Africa and generally over-represented in rural, remote, and impoverished agricultural communities. While poverty is an established risk factor, little research has been done to investigate the economic consequences of SBE. This cross-sectional, quantitative study aimed to measure out-of-pocket spending and lost income when a household member was bitten by a snake. In 2020, 732 snakebite survivors from Eastern Province (Rwanda) agreed to complete a survey administered by telephone. The survey focused on participant demographics, income, direct medical and non-medical costs, care-seeking decisions, and lost work during convalescence. Our results suggested that patients incurred the highest mean expenses when they sought care from hospitals (11 307 RWF or 12 USD) or traditional healers (5 836 RWF or 6 USD) but that the highest maximum cost was incurred from traditional healers (300 000 RWF or 313 USD). Across all victims, the total amount paid to traditional healers (3.4 million RWF or 3 537 USD) was 4.7 times higher than all other care providers combined. On average, families lost 111 814 RWF (117 USD) per snakebite in direct treatment costs and indirect productivity losses. Many victims sought care from traditional healers despite being eligible for free medical care. Altogether, this study serves as a reminder of the serious physical and financial consequences associated with SBE and provides justification for new investments into SBE prevention and care.