Prevalence of mental disorders, associated co-morbidities, health care knowledge and service utilization in Rwanda - towards a blueprint for promoting mental health care services in low- and middle-income countries?

BACKGROUND: In order to respond to the dearth of mental health data in Rwanda where large-scale prevalence studies were not existing, Rwanda Mental Health Survey was conducted to measure the prevalence of mental disorders, associated co-morbidities and knowledge and utilization of mental health services nationwide within Rwanda. METHODS: This cross-sectional study was conducted between July and August 2018, among the general population, including survivors of the 1994 Genocide against the Tutsi. Participants (14-65 years) completed the Mini-International Neuropsychiatric Interview (Version 7.0.2), sociodemographic and epilepsy-related questionnaires. General population participants were selected first by random sampling of 240 clusters, followed by systematic sampling of 30 households per cluster. Genocide survivors within each cluster were identified using the 2007-2008 Genocide Survivors Census. RESULTS: Of 19,110 general survey participants, most were female (n = 11,233; 58.8%). Mental disorders were more prevalent among women (23.2%) than men (16.6%) (p < 0.05). The most prevalent mental disorders were major depressive episode (12.0%), panic disorder (8.1%) and post-traumatic stress disorder (PTSD) (3.6%). Overall, 61.7% had awareness of mental health services while only 5.3% reported to have used existing services. Of the 1271 genocide survivors interviewed, 74.7% (n = 949) were female; prevalence of any mental disorder was 53.3% for women and 48.8% for men. Most prevalent disorders were major depressive episode (35.0%), PTSD (27.9%) and panic disorder (26.8%). Among genocide survivors, 76.2% were aware of availability of mental health services, with 14.1% reported having used mental health services. CONCLUSIONS: Despite high prevalence of mental disorders among the general population and genocide survivors, utilization of available mental health services was low. A comprehensive approach to mental health is needed for prevention of mental illness and to promote mental healthcare services.

Mixed methods study design, pre-analysis plan, process evaluation and baseline results of trailbridges in rural Rwanda.

We present a study design, pre-analysis plan, process evaluation and baseline results designed to establish the impact of trailbridges on health, education, agricultural and economic outcomes of households in rural Rwanda. This intervention and study is being implemented in communities that face barriers to socioeconomic development through periodic isolation caused by flooding. We describe a mixed methods approach to measure the impacts of these trailbridges on outcomes at the village level. The study is anchored on a stepped-wedge randomized controlled trial (RCT) implemented in 147 sites: 97 phased-in intervention sites and 50 long-term control sites. These sites are being monitored in four annual waves comprising of a baseline period and three subsequent follow-up waves. We will supplement the RCT with three sub-studies. First, we are investigating the role of weather events and streamflow variability on temporal and spatial bridge use patterns among intervention sites. We will then find the relationship between the weather events, streamflow and bridge use from motion-activated cameras installed in intervention sites. Secondly, we are following 42 markets serving study sites to investigate the impact of the trailbridges on the market prices of key goods including crops, livestock and agricultural inputs. Lastly, we are following 30 villages that are more distant from the river crossings to determine the spatial extent of the trailbridge impacts. Our study will advance knowledge by generating new data on the impact of rural infrastructure and providing the opportunity to explore a range of outcomes for future evaluation of infrastructure in low- and middle-income countries. We will enable an outcomes-based funding model that ties implementer payments to demonstrated positive impacts of these trailbridges. Furthermore, we will identify cost-effective, easily assessed measures that are highly correlated to the economic and health benefits of the intervention. These measures may then be used by a portfolio of interventions across multiple geographies without always requiring complex trials.

Engineering environmental resilience: A matched cohort study of the community benefits of trailbridges in rural Rwanda.

Rural isolation can limit access to basic services and income-generating opportunities. Among some communities, rainfall induced flooding can cause increased uncertainty where first-mile transportation infrastructure is limited. In Rwanda, this challenge is apparent, where 90% of the population below the poverty line live in rural areas that are typically mountainous with frequent flooding - events that may be increasing in frequency and severity as the climate changes. To reduce these transportation barriers, the non-profit organization Bridges to Prosperity (B2P) plans to construct hundreds of trailbridges in Rwanda between 2018 and 2023. This scale of rural infrastructure services presents an opportunity for experimental investigation of the effects of these new trailbridges on economic, health, agricultural and education outcomes in rural communities. In this paper, we present a cohort study evaluating the potential community benefits of rural trailbridges - including economic, health and social outcomes for Rwandan communities experiencing environmental change. We examined households living near 12 trailbridge sites and 12 comparison sites over February 2019-March 2020. We found that labor market income increased by 25% attributable to the trailbridges. We did not observe any significant effects on agricultural income, education or health outcomes, however given the small sample and short duration of this study we anticipate observing additional outcomes within the recently started 200 site, 4 year trial.

Computer vision supported pedestrian tracking: A demonstration on trail bridges in rural Rwanda.

Trail bridges can improve access to critical services such as health care, schools, and markets. In order to evaluate the impact of trail bridges in rural Rwanda, it is helpful to objectively know how and when they are being used. In this study, we deployed motion-activated digital cameras across several trail bridges installed by the non-profit Bridges to Prosperity. We conducted and validated manual counting of bridge use to establish a ground truth. We adapted an open source computer vision algorithm to identify and count bridge use reflected in the digital images. We found a reliable correlation with less than 3% error bias of bridge crossings per hour between manual counting and those sites at which the cameras logged short video clips. We applied this algorithm across 186 total days of observation at four sites in fall 2019, and observed a total of 33,800 daily bridge crossings ranging from about 20 to over 1,100 individual uses per day, with no apparent correlation between daily or total weekly rainfall and bridge use, potentially indicating that transportation behaviors, after a bridge is installed, are no longer impacted by rainfall conditions. Higher bridge use was observed in the late afternoons, on market and church days, and roughly equal use of the bridge crossings in each direction. These trends are consistent with the design-intent of these bridges.

PTSD prevalence among resident mothers and their offspring in Rwanda 25 years after the 1994 genocide against the Tutsi.

BACKGROUND: The 1994 Genocide against the Tutsi was a major traumatic event affecting nearly all Rwandans. Significant psychological sequels continue to occur in the population 25 years after, with a high prevalence of posttraumatic stress disorder (PTSD) found in women. Three groups are typically designated with regard to the Genocide against the Tutsi: those who were targeted and categorized as genocide "survivors," those who were in the country during the genocide and were the "non-targeted" group, and those who were outside of the country, referred to as the "1959 returnees." Each group experienced various traumatic events during and in the aftermath of the genocide. Offspring of the designated groups, currently exhibit symptoms of PTSD disregarding of being born in the years following the genocide. A number of studies have described the prevalence of PTSD in the general adult population. There is a lack of research comparing the prevalence of PTSD in women and their offspring among these three target groups, therefore, this study aimed to bridge the gap. METHODS: We conducted a comparative cross-sectional study with a sample of 432 mothers and 432 children in three categories: genocide survivors, in country non-targeted and 1959 returnees. Participant ages for children were between 14 to 22 years and for mothers, between the ages of 32 to 87 years. The UCLA-PTSD DSM-5, PTSD Check list-5 and Life events Checklist-5 were translated from English to Kinyarwanda and were used to assess exposure to trauma and the prevalence of PTSD symptoms in Rwandan mothers and their offspring. RESULTS: Key Results yield a PTSD rate of 18.8, 6.2, 5.2% within survivors, in country non-targeted, and returnees respectively with an average PTSD rate of 43.8% for parents, and 16.5% for offspring. CONCLUSION: PTSD among the mothers' groups and their offspring have been found, specifically in the offspring of genocide survivors. Considering these adolescents were not born at the time of the 1994 Genocide against the Tutsi, the results suggest future studies should explore the precipitating factors contributing to the PTSD symptoms within this specific group.

Approaches and impact of non-academic research capacity strengthening training models in sub-Saharan Africa: a systematic review.

BACKGROUND: Research is essential to identify and prioritize health needs and to develop appropriate strategies to improve health outcomes. In the last decade, non-academic research capacity strengthening trainings in sub-Saharan Africa, coupled with developing research infrastructure and the provision of individual mentorship support, has been used to build health worker skills. The objectives of this review are to describe different training approaches to research capacity strengthening in sub-Saharan Africa outside academic programs, assess methods used to evaluate research capacity strengthening activities, and learn about the challenges facing research capacity strengthening and the strategies/innovations required to overcome them. METHODOLOGY: The PubMed database was searched using nine search terms and articles were included if 1) they explicitly described research capacity strengthening training activities, including information on program duration, target audience, immediate program outputs and outcomes; 2) all or part of the training program took place in sub-Saharan African countries; 3) the training activities were not a formal academic program; 4) papers were published between 2000 and 2013; and 5) both abstract and full paper were available in English. RESULTS: The search resulted in 495 articles, of which 450 were retained; 14 papers met all inclusion criteria and were included and analysed. In total, 4136 people were trained, of which 2939 were from Africa. Of the 14 included papers, six fell in the category of short-term evaluation period and eight in the long-term evaluation period. Conduct of evaluations and use of evaluation frameworks varied between short and long term models and some trainings were not evaluated. Evaluation methods included tests, surveys, interviews, and systems approach matrix. CONCLUSIONS: Research capacity strengthening activities in sub-Saharan Africa outside of academic settings provide important contributions to developing in-country capacity to participate in and lead research. Institutional support, increased funds, and dedicated time for research activities are critical factors that lead to the development of successful programs. Further, knowledge sharing through scientific articles with sufficient detail is needed to enable replication of successful models in other settings.