Knowledge and practices surrounding outbreaks and COVID-19 among community health workers in rural Rwanda: a cross-sectional mixed-methods study

Introduction: Community Health Workers (CHW) are a critical resource for outbreak preparedness and response. However, CHWs´ ability to respond to outbreaks depends on their accurate knowledge of the disease and proper adoption of disease prevention practices. We explored knowledge and practices related to outbreaks in general, and COVID-19 among CHWs in Rwanda. Methods: this cross-sectional multimethod study used stratified simple random sampling to recruit three cadres of CHWs (agents de santé maternelle, female Binomes, and male Binomes ) from three rural Rwandan districts. We used telephone-based data collection to administer quantitative surveys (N=292) and qualitative interviews (N=24) in September 2020. We calculated descriptive statistics and conducted thematic analysis of qualitative data. We assessed for associations between general outbreak-related knowledge and receipt of training using Chi-square tests and between COVID-19 related knowledge and CHW characteristics and adoption of prevention methods using linear regression models. Results: only 56.2% of CHWs had received training on any health topic in 12 months prior to COVID-19 pandemic and only 19.2% had specifically received training on outbreak preparedness. Almost all CHWs reported preventing COVID-19 by wearing facemasks (98%), washing hands (95%), and social distancing in crowds (89%) with fewer reporting staying at home (50%), sneezing or coughing into an elbow (38%) or using hand sanitizer (18%). Almost all CHWs in our study knew that COVID-19 transmit through respiratory droplets (98%) and by infected surfaces (98%) and that asymptomatic spread is possible (91%). However, fewer than half of community health workers correctly affirmed that children were at low risk of becoming severely ill (48%) and only 32% correctly rejected the misconception that everyone with COVID-19 would become severely ill. There was no association between COVID-19-related knowledge and adoption of COVID-19 preventative practices. Qualitative findings suggested that while CHWs possessed lots of correct information about COVID-19 and reported good adherence to COVID-19 prevention practices, they also commonly held misconceptions that over-exaggerated the dangers of COVID-19. Conclusion: gaps in knowledge, training, and access to information point to a need for additional investment in supervision and credible informational systems to support CHWs.

Rwandan primary healthcare providers' perception of their capability in the diagnostic practice

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