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Background: Indoor residual spraying (IRS) has been implemented in Rwanda in districts with high malaria transmission, including Ngoma District. The first IRS campaign (IRS-1) was conducted in March 2019, ahead of the peak malaria season, followed by a second campaign (IRS-2) in August 2020, targeting 89,331 structures. This study assessed factors influencing IRS uptake and evaluated the impact of IRS interventions on malaria morbidity in Ngoma District, Eastern Province, Rwanda., Methods: A household survey employing multistage cluster sampling design was conducted in May 2021 to randomly select households. A structured questionnaire was administered to the head of household or a designated representative. Logistic regression, adjusted for the complex survey design and weighted for sampling, was used to identify factors associated with IRS uptake. Additionally, secondary data on malaria cases registered in the Rwanda Health Management Information System (RHMIS) from January 2015 to December 2022 were analyzed using interrupted time series analysis to evaluate the effect of IRS on malaria morbidity., Results: A total of 636 households participated in the survey. Households headed by self-employed individuals (aOR = 0.07; 95% CI 0.01-0.55) and unemployed individuals (aOR = 0.18; 95% CI 0.03-0.99) were less likely to take up IRS compared to those headed by farmers. Households receiving IRS information through media channels (aOR = 0.01; 95% CI 0.00-0.17) were less likely to participate compared to those informed by community health workers. From the RHMIS data, 919,843 malaria cases were identified from January 2015 to December 2022. Interrupted time series analysis revealed that the baseline number of adjusted malaria cases was approximately 16,920. The first IRS intervention in March 2019 resulted in a significant reduction of 14,380 cases (p < 0.001), while the second intervention in August 2020 led to a reduction of 2495 cases, though this was not statistically significant (p = 0.098)., Conclusion: This study demonstrates the effectiveness of IRS in reducing malaria incidence in Ngoma District and highlights the role of socioeconomic factors and sources of information in influencing IRS uptake. To maximize the impact of IRS and ensure equitable benefits, targeted strategies, enhanced IRS education, and integrated malaria control approaches, including the use of bed nets, are crucial., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Pregnancy among adolescents is a significant public health concern worldwide, particularly in developing countries, including Rwanda. Although contraception could be an effective tool to prevent unintended pregnancy, its utilization among adolescents is often low., Aim: This study explored knowledge, attitudes and strategies on contraceptive utilization among adolescents., Methods: Mixed method research (MMR) using a cross-sectional design, Sequential explanatory design was used to explore the views from 394 participants in Gitega Sector. This approach was chosen to first quantify the prevalence and patterns of contraceptive use through the questionnaire-based survey, and then to deepen understanding by exploring attitudes, beliefs, and experiences of adolescents and parents through in-depth interviews and focus group discussions. This sequential approach allowed quantitative findings to guide qualitative inquiry, providing richer context to the statistical data. For the quantitative phase, convenience sampling facilitated by the in charge of Health at the sector level and community health workers at the cell level ensured effective access to the study's target demographic. Qualitative participants were purposively chosen to gain detailed insights from those identified with unique or significant experiences in the initial survey. Data were analyzed using SPSS version 25.0 for quantitative analysis and ATLAS.ti 23 for qualitative analysis., Results: The study found that both adolescents and parents (59.1%) have a low level of knowledge about contraceptive utilization, with adolescents (75.5%) showing significantly lower knowledge than parents (46.4%). A majority of the participants, 195 (56.7%), had a positive attitude towards contraceptive utilization among adolescents. Bivariate analysis revealed significant associations between knowledge and socio-demographic factors such as education (P = 0.00) and marital status (P = 0.00), indicating higher knowledge levels among those with higher educational attainment and married individuals. Additionally, attitudes towards contraceptive utilization were significantly influenced by occupation (P = 0.005) and religion (P = 0.00). However, challenges such as the lack of parent-child communication and low knowledge contributed to the low contraceptive usage despite the existing initiatives such as the INGOBYI Activity., Conclusion: The findings highlight a need for targeted interventions that address the specific challenges identified, including the lack of knowledge and communication barriers. Improved education and awareness programs for both adolescents and parents, along with supportive community strategies, may enhance contraceptive utilization. A concerted effort involving parents, healthcare providers, and community leaders may foster a supportive environment that encourages responsible and informed contraceptive use among adolescents., Competing Interests: Declarations. Ethics approval and consent to participate: For this research to be conducted, Ethical clearance was obtained from Institution Review Board (IRB) of UR/CMHS (Ref: CMHS/IRB/OO2/2023). The Ethical Clearance submitted to City of Kigali to obtain authorization for data collection in Nyarugenge District, Gitega sector. The researchers gave clear explanations to the participants regarding the study including the main objective beforehand of data collection. The participants were informed that it was voluntary participation. Confidentiality of participants was ensured by giving identification codes instead of names. Participants who accepted to participate voluntarily, were given consent form to sign and were interviewed face to face. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Malaria remains a significant concern for children under five in malaria-endemic regions. Rwanda's successful efforts in malaria treatment reduced nationwide cases, but high mortality persists in the Eastern and Southern provinces. This study aimed to investigate the clinical features of severe malaria and to identify the death risk factors among under-five children in Eastern province Hospitals., Methods: This cross-sectional study assessed severe malaria-related mortality and associated factors among children aged under five years in hospitals of Eastern Province, Rwanda, from 2017 to 2021. Data were collected from hospital records, and descriptive statistics and logistic regression were used for data analysis., Results: Factors associated with severe malaria-related mortality included coma (aOR: 10, 95% CI: 1.2-82.5, p = 0.03), Vomiting (aOR: 5.2, 95% CI: 1.0-26.0, p = 0.04), four or more days of illness before consultation (aOR: 30.9, 95% CI: 8.7-109.9, p < 0.01). On the other hand, a low parasitaemia level (aOR: 0.01, 95% CI: 0.0-0.1, p < 0.01)., Conclusion: In conclusion, coma, vomiting, and healthcare delays increased mortality in children with severe malaria. Prompt treatment, proper assessments, protocol adherence, and caregiver education on early symptom recognition are crucial for improving outcomes., Competing Interests: Declarations Ethics approval and consent to participate The studies involving human participants were reviewed and approved by the College of Medicine and Health Sciences, University of Rwanda and the permission to access patients’ files was given by the Hospital administration. No consent or ascent was required as we used secondary data. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Climate change and recurring droughts-induced effects on health are becoming an increasingly main global, cultural and public health burden. The heaviest health burden leans on the fragile socio-economic systems among the remote agro-pastoral communities, living in the arid and semi-arid lands (ASALs). Previous studies underlined the indispensability of indigenous knowledge (IK) for resilience-driven disaster risk reduction (DRR) strategies. However, more attention has been drawn towards the necessity of IK in weather forecasts, with less emphasis on its indispensability to alleviate health burden associated with climate change and droughts. We explored the contextual application of IK-based adaptation and related complementarity aspects for culturally relevant and sustainable DRR strategies for the nomadic agro-pastoral communities in Lopur, Turkana, Kenya. Relying on a descriptive qualitative study in phenomenological approach, purposive sampling and focus group discussions with key community influencers, a thematic analysis was conducted for an in-depth understanding and interpretation of data patterns. The contextualised insights revealed the growing vulnerability as a result of the disconnect between modern interventions, IK and the newly adopted environmental degrading coping tactics. Policy-wise, the findings portrayed the necessity for cultural integration and incorporation of indigenous knowledge-based strategies and systems for reinforced information dissemination, accessibility and acceptability for droughts preparedness and response., Contribution: This study underlined the existing room for scientific exploration of the already existing indigenous knowledge-based solutions for food and water insecurity, towards improved resilience for the vulnerable communities experiencing inequitable climate change calamities in the ASALs., Competing Interests: The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article., (© 2024. The Authors.)

Air pollution is a global environmental and public health challenge. There is limited evidence about the air quality in Rwanda, and the concentrations of particulate matter (PM), namely PM 2.5 and PM 10 in schools have not been well documented. This study evaluated patterns and disparities in indoor PM levels in selected primary schools in Kigali, Rwanda. The study collected PM 2.5 and PM 10 concentrations from six classrooms in six selected primary schools during the regular school study period in the dry season. Data were collected using mobile air sensors (purple air/PA-II-SD air quality) and an observation checklist. A Kruskal-Wallis test was performed to assess the difference in PM 2.5 and PM 10 concentrations between the six schools. The post-hoc Mann-Whitney test was used to compare all group pairs. The results indicated a significant difference in both the indoor PM 2.5 concentration (H (5) = 41.01, p < 0.001) and the indoor PM 10 concentration (H (5) = 38.5, p < 0.001). The maximum concentration observed was 133.6 μg/m 3 for PM 2.5 and 158.5 μg/m 3 for PM 10 . Schools in highly exposed areas tended to have higher concentrations of PM than schools in moderately exposed areas. Specifically, the daily average concentration of PM 2.5 in schools located in highly exposed areas ranged from 39 μg/m³ to 118 μg/m³, while PM 10 levels ranged from 44.0 μg/m³ to 126 μg/m³. In contrast, schools in moderately exposed areas had daily PM 2.5 average concentrations ranging from 32.0 μg/m³ to 111.0 μg/m³ and daily PM 10 average concentrations ranging from 38.0 μg/m³ to 119 μg/m³. Overall, the recorded values for both PM 2.5 and PM 10 in all sampled schools were higher than the World Health Organization air quality guidelines. Indoor air quality is poorer in schools situated in highly exposed areas. This study suggests interventions to improve school air quality for the benefit of school communities., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

The disease burden related to air pollution from traditional solid-fuel cooking practices in low- and middle-income countries impacts millions of people globally. Although the use of liquefied petroleum gas (LPG) fuel for cooking can meaningfully reduce household air pollution concentrations, major barriers, including affordability and accessibility, have limited widespread adoption. Using a randomized controlled trial, our objective was to evaluate the association between the cost and use of LPG among 23 rural Rwandan households. We provided a 2-burner LPG stove with accessories and incorporated a "pay-as-you-go" (PAYG) LPG service model that included fuel delivery. PAYG services remove the large up-front cost of cylinder refills by integrating "smart meter" technology that allows participants to pay in incremental amounts, as needed. We assigned three randomized discounted prices for LPG to each household at ~4-week intervals over a 12-week period. We modeled the relationship between randomized PAYG LPG price and use (standardized to monthly periods), analyzing effect modification by relative household wealth. A 1000 Rwandan Franc (about 1 USD at the time of the study) increase in LPG price/kg was associated with a 4.1 kg/month decrease in use (95% confidence interval [CI]: -6.7, -1.6; n=69 observations). Wealth modified this association; we observed a 9.7 kg/month reduction (95% CI: -14.8, -4.5) among wealthier households and a 2.5 kg/month reduction (95% CI: -5.3, 0.3) among lower-wealth households (p-interaction=0.01). The difference in price sensitivity was driven by higher LPG use among wealthier households at more heavily discounted prices; from an 80% to 10% discount, wealthy households used 17.5 to 5.3 kg/month and less wealthy households used 6.2 to 3.1 kg/month. Our pilot-level experimental evidence of PAYG LPG in a rural low-resource setting suggests that further exploration of subsidized pricing varied by household wealth is needed to ensure future policy initiatives can achieve targets without exacerbating inequities., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Introduction: Rwanda's Hepatitis C elimination campaign has relied on mass screening campaigns. An alternative "micro-elimination" strategy focused on specific populations, such as non-communicable disease (NCD) patients, could be a more efficient approach to identifying patients and linking them to care., Methods: This retrospective cross-sectional study used routine data collected during a targeted screening campaign among NCD patients in Kirehe, Kayonza, and Burera districts of Rwanda and patients receiving oncology services from the Butaro District Hospital. The campaign used rapid diagnostic tests to screen for Hepatitis B surface antigen (HBsAg) and Hepatitis C antibody (anti-HCV). We reported prevalences and 95% confidence intervals for HBsAg and anti-HCV, assessed for associations between patients' clinical programs and hepatitis B and C, and reported cascade of care for the two diseases., Results: Out of 7,603 NCD patients, 3398 (45.9%) self-reported a prior hepatitis screening. Prevalence of HBsAg was 2.0% (95% CI: 1.7%-2.3%) and anti-HCV was 6.7% (95% CI: 6.2%-7.3%). The prevalence of HBsAg was significantly higher among patients < 40 years (2.4%). Increased age was significantly associated with anti-HCV (12.0% among patients ≥ 70 years). Of the 148 individuals who screened positive for HbsAg, 123 had viral load results returned, 101 had detectable viral loads (median viral load: 451 UI/mL), and 12 were linked to care. Of the 507 individuals who screened positive for anti-HCV, 468 had their viral load results returned (median viral load: 1,130,000 UI/mL), 304 had detectable viral loads, and 230 were linked to care., Conclusion: Anti-HCV prevalence among Rwandan patients with NCD was high, likely due to their older age. NCD-HCV co-infected patients had high HCV viral loads and may be at risk of poor outcomes from hepatitis C. Hepatitis C micro-elimination campaigns among NCD patients are a feasible and acceptable strategy to enhance case detection in this high-prevalence population with elevated viral loads and may support linkage to care for hepatitis C among elderly populations., (© 2024. The Author(s).)

Background: Access to safe, effective, affordable, and high-quality medications has been included in the Sustainable Development Goals (SDGs) of the United Nations as a crucial step towards attaining universal health coverage. Access to medicines is a fundamental human right. If medicines are accessible and affordable, they save lives by reducing mortality and morbidity associated with acute and chronic diseases. WHO recommends that all countries voluntarily reach the minimum target of 80% availability of medicines by 2025. The primary purpose of this research is to assess access to essential medicines in Juba County, South Sudan., Methods: This study was undertaken using the standard World Health Organization/Health Action International Organization (WHO/HAI) approach for surveying the prices, availability, and affordability of medicines. A survey was conducted in six payams of Juba County, South Sudan, and 55 health facilities were assessed., Results: Prices for generic medicines were better in faith-based health facilities with a median price ratio of 1.95. Private pharmacies and private clinics had MPRs of 4.64 and 4.32, respectively. Local prices were high compared to International referent prices. Availability of medicines was highest in the faith-based health facilities (65.5%) and slightly lower in private pharmacies (55.4%), private clinics (57.7%) and public (50.4%) sectors. Most of the surveyed medicines were unaffordable. The medicines needed to treat non-communicable diseases cost up to 33.7-day wages for one full course of treatment., Conclusions: In South Sudan, medicines are poorly available in all sectors. Medicines are affordable in the public sector but Most medicines are unaffordable in private pharmacies, private clinics and faith-based health facilities. Poor medicines availability in the public sector contributes to the overall unaffordability of medicines in all the other sectors., (© 2023. The Author(s).)

Ecological sanitation (Ecosan) by-products are inherently limited in their potential use as excreta resources. Disgust behind human excreta and derivatives continues to challenge the further use of Ecosan-by products. Although treated excreta, including Ecosan by-products, have gradually been adopted worldwide, diverse perspectives among users hinder their use in agro-practices. This study explored perceptions of the use of Ecosan-by products as relates to the disgust of human excreta among rural farmers in Burera district, Rwanda. A qualitative study was conducted amongst three farmers' cooperatives using Ecosan by-products. We conducted six focus group discussions (FDGs) comprising a total of 48 participants taking into account the following three themes: core excreta disgust, perceived waste, and perceived resource. Thematic analysis was conducted with similar perspectives identified and grouped under emerging sub-themes. The perspectives regarding disgust elicitors included stigma, eversion, phobia, taboos, and health risks. Ecosan by-products were largely perceived as useful, with most farmers trusting and willing to touch the by-products. Psychosocial barriers to using the by-products continued to slow down the adoption of Ecosan for agricultural options. There is a need for increased awareness to scale up the use of Ecosan coupled with effective treatment practices for the products so as to reverse the psychological barriers resulting from traditional excreta disgust over Ecosan-products of faeces and urine.

Chronic exposure to indoor and outdoor air pollution is linked to adverse human health impacts worldwide, and in children, these include increased respiratory symptoms, reduced cognitive and academic performance, and absences from school. African children are exposed to high levels of air pollution from aging diesel and gasoline second-hand vehicles, dusty roads, trash burning, and solid-fuel combustion for cooking. There is a need for more empirical evidence on the impact of air pollutants on schoolchildren in most countries of Africa. Therefore, we conducted a scoping review on schoolchildren's exposure to indoor and outdoor PM 2.5 (particulate matter with an aerodynamic diameter less than 2.5 μm and PM 10 (particulate matter with an aerodynamic diameter less than 10 μm) in Africa. Following PRISMA guidelines, our search strategy yielded 2975 records, of which eight peer-reviewed articles met our selection criteria and were considered in the final analysis. We also analyzed satellite data on PM 2.5 and PM 10 levels in five African regions from 1990 to 2019 and compared schoolchildren's exposure to PM 2.5 and PM 10 levels in Africa with available data from the rest of the world. The findings showed that schoolchildren in Africa are frequently exposed to PM 2.5 and PM 10 levels exceeding the recommended World Health Organization air quality guidelines. We conclude with a list of recommendations and strategies to reduce air pollution exposure in African schools. Education can help to produce citizens who are literate in environmental science and policy. More air quality measurements in schools and intervention studies are needed to protect schoolchildren's health and reduce exposure to air pollution in classrooms across Africa., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: The utilization of "on-site excreta decomposition technology" known as "Ecological sanitation (Ecosan)" has a rational use of human excreta. It is a resource-oriented sanitation mostly feasible in areas with rocky soil and prone to agriculture. This technology was implemented in Rwanda for more than a decade. However, little is known about Ecosan utilization in the process of scale-up in the community., Aim: The study was carried out to determine enablers and barriers associated with the utilization of Ecosan in Burera district, Rwanda., Methods: A mixed method study was surveyed in 374 households with Ecosan. A systematic random sampling was used to select respondents and a sample was drawn from the 3 administrative sectors of Burera district. We interviewed 20 key informants that included community leaders and sanitation actors. Bivariate, ordered logistic regression with thematic content analysis were used., Results: Ecosan users were unable to practice both urine diversion and the use of Ecosan by-products. Only 39.4% of households were better users. As by the survey results, primary and secondary educational status (AOR 2.60, 95% CI 1.11-6.08) and (AOR 3.49, 95% CI 1.02-11.9), frequency of fecal pit emptying (AOR 3.38, 95% CI (2.18-17.91), ash use (AOR 1.65, 95% CI (0.93-4.64) and concrete slab latrine (AOR 7.31, 95% CI (2.94-17.95) were found to be associated with better use of Ecosan. Qualitative findings suggested unaffordable cost, a touch of excreta taboos, and poor maintenance practices as key barriers to utilization., Conclusion: Overall utilization of Ecosan was poor and the majority of households was not able to use Ecosan for both dry separation of urine from feces and reuse in the gardens. Upgrading existing knowledge about Ecosan with greater emphasis on the use of by-products and adopting good maintenance practices through regular training can promote better utilization of Ecosan., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)