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Arthropod-borne (arbo) viruses cause emerging diseases that affect the livelihoods of people around the world. They are linked to disease outbreaks resulting in high morbidity, mortality, and economic loss. In sub-Saharan Africa, numerous arbovirus outbreaks have been documented, but the circulation and magnitude of illness caused by these viruses during inter-epidemic periods remains unknown in many regions. In Rwanda, there is limited knowledge on the presence and distribution of arboviruses. This study aimed at determining the occurrence and distribution of selected arboviruses, i.e., chikungunya virus (CHIKV), o’nyong-nyong virus (ONNV), dengue virus (DENV), West Nile virus (WNV), Zika virus (ZIKV), Rift Valley fever virus (RVFV) and Crimean-Congo haemorrhagic fever virus (CCHFV), among febrile patients visiting health centres in Rwanda. A total of 2294 dry blood spots (DBS) were collected on filter papers during August 2019 – December 2020. Reverse-transcription polymerase chain reaction (RT-PCR) was performed on samples in pools of ten, using both quantitative (DENV, ZIKV, RVFV) and conventional PCR (CHIKV, ONNV, WNV, CCHFV) with virus specific primers, followed by sequencing. Demographic data and clinical manifestations of illness were analysed. ONNV infection was detected in 12 of 230 pools (5.2%) and ZIKV in three pools (1.3%). The other arboviruses were not detected. All ONNV cases were found in the Rwaniro health centre, while ZIKV infection was found among patients visiting the Kirinda and Zaza health centres. There was temporal variability in ONNV infections with most cases being recorded during the long dry season, while ZIKV infection occurred during both dry and wet seasons. Patients with ONNV were older and more were females. In conclusion, ONNV and ZIKV infection were detected in acute patients and can explain some of the feverish diseases in Rwanda.

BACKGROUND: Quality healthcare is a global priority, reliant on robust health systems for evidence-based medicine. Clinical laboratories are the backbone of quality healthcare facilitating diagnostics, treatment, patient monitoring, and disease surveillance. Their effectiveness depends on sustainable delivery of accurate test results. Although the Strengthening Laboratory Management Towards Accreditation (SLMTA) programme has enhanced laboratory quality in low-income countries, the long-term sustainability of this improvement remains uncertain.

OBJECTIVE: To explore the sustainability of quality performance in clinical laboratories in Rwanda following the conclusion of SLMTA.

METHODS: A quasi-experimental design was adopted, involving 47 laboratories divided into three groups with distinct interventions. While one group received continuous mentorship and annual assessments (group two), interventions for the other groups (groups one and three) ceased following the conclusion of SLMTA. SLMTA experts collected data for 10 years through assessments using WHO's StepwiseLaboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. Descriptive and t-test analyses were conducted for statistical evaluation.

RESULTS: Improvements in quality were noted between baseline and exit assessments across all laboratory groups (mean baseline: 35.3%, exit: 65.8%, p < 0.001). However, groups one and three experienced performance declines following SLMTA phase-out (mean group one: 64.6% in reference to 85.8%, p = 0.01; mean group three: 57.3% in reference to 64.7%, p < 0.001). In contrast, group two continued to enhance performance even years later (mean: 86.6%compared to 70.6%, p = 0.03).

CONCLUSION: A coordinated implementation of quality improvement plan that enables regular laboratory assessments to pinpoint and address the quality gaps is essential for sustaining quality services in clinical laboratories.

Background: To address the challenges of limited national data on the prevalence and nature of violence experienced by children, Rwanda conducted, in 2015–2016, the first National Survey on Violence among female and male children and youth aged 13–24 years. To further contribute to these efforts to fill existing data gaps, we used the Rwanda survey data to assess the prevalence and predictors of physical violence (PV) in children aged 13–17.

Methods: A nationally representative sample of 618 male and 492 female children were analysed. Nationally representative weighted descriptive statistics were used to analyse the prevalence of PV self-reported by children, and logistic regression models were applied to investigate its predictors.

Results: Sixty percent of all children, including 36.53% of male and 23.38% of female children, reported having experienced any form of PV in their lifetime. Additionally, 21.81% of male children and 12.73% of female children reported experiences of PV within twelve months before the survey date. Older children (OR: 0.53 [0.40–0.72]), female children (OR: 0.43 [0.31–0.58]), and children not attending school (OR: 0.48 [0.31–0.73]) were less likely to be physically abused. However, sexually active children (OR: 1.66 [1.05–2.63]), children in households from the middle wealth quintile (OR: 1.63 [1.08–2.47]), children living in a larger family (OR: 1.55 [1.07–2.26]), and children who reported not feel close to both biological parents (OR: 2.14 [1.31–3.49]) had increased odds of reporting physical violence.

Conclusion: Higher rates of PV in children attending school were the key finding. There is an urgent need to design and implement particular national interventions to prevent and reduce the incidence of PV in schools in Rwanda. PV was also associated with poor parent-child relations. Parents and other adult caregivers should be sensitised to the consequences of PV on children and be urged to adopt positive parenting practices.

Introduction: Poor quality health care is a serious silent public health problem worldwide, resulting in deaths, disabilities and long hospital stays with unnecessary costs. It affects patients in all countries regardless of their level of development. Estimations show that 64 million disability-adjusted life years are lost yearly worldwide due to unsafe health care, and this phenomenon is one of the top 10 causes of mortality and disability in the world. Four out of 10 patients are harmed while getting health care in primary and outpatient health care services. Most of this unsafe care is due to errors in diagnosis, prescriptions and use of medicines. Better management of patients could be accomplished with clearer diagnostics. Clinical laboratories play a central role in the quality of health care when they provide accurate and reliable test results for timely and evidence-based diagnostic for management of patients, surveillance and control of diseases. The aim of this dissertation was to study the quality of clinical laboratory services in Rwanda to contribute to the health care quality in Rwanda and other similar settings.

Methods: This dissertation is built on studies that used mainly primary data collected at five clinical referral laboratories and related hospitals (Papers I–III). To assess the quality performance of laboratories, the World Health Organization (WHO) Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) checklist was used to score laboratories and to analyse the trend in quality performance (Paper I). The factors explaining the status of quality performance of laboratories were explored by using qualitative data, namely key informant interviews with thematic analysis (Paper II). Physicians’ satisfaction with laboratory services was assessed by using a structured questionnaire with a Likert scale and an open-ended question. All eligible physicians from four referral hospitals (N = 507) were invited to participate in the study (Paper III) and 91% provided their feedback. Descriptive statistics and ordered logistic regression were performed and qualitative data were analysed with a thematic approach. To identify pathogenic viruses circulating in Rwanda with no available diagnosis, we sampled 11 health centres for febrile patients with acute infections whose malaria test result was negative (n = 2313). Selected arboviruses were analysed from blood samples by using polymerase chain reaction (Paper IV).

Results and Discussion: In 2017, only one referral laboratory scored at the highest level, five stars, which was an increase from four stars in 2012. The other four laboratories had decreased in quality performance. The factors explaining this decrease were mainly insufficient coordination to ensure continuous quality improvement as well as lack of mentorship and regular external assessment of laboratory to identify and address gaps. Only 36% of physicians were satisfied with laboratory services in referral hospitals. Seventy per cent were satisfied with the reliability of test results, while only 19% were satisfied with the turnaround time, and improved virus diagnostics was sought. In general, paediatricians, internists and more experienced physicians were less satisfied. Over 2000 samples from acute, febrile patients were sampled in 11 health centres from different provinces of Rwanda and are now stored in a unique biobank for future analysis. The results so far show that o’nyong-nyong and Zika viruses are circulating in Rwanda.

Conclusion: Despite the improvement in quality performance with the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme, most laboratories showed decreased performance in their follow-up assessments compared with their exit assessment. Resuming external assessments as well as investing in leadership and planning would lead to high-quality laboratory performance, even reaching international accreditation. For sustainability, the SLMTA programme should be institutionalised, the laboratory quality management system should be integrated into the education of laboratory staff and in continuous professional development training. Extended diagnostics for infectious diseases should be considered. The achievement of quality health care, universal health coverage and global health security are not possible without quality laboratory services that guide the pathway through accurate and reliable tests results.

BACKGROUND: The quality of laboratory services is crucial for quality of patient care. Clinical services and physicians' decisions depend largely on laboratory test results for appropriate patients' management. Therefore, physicians' satisfaction with laboratory services is a key measurement of the quality service that stresses impactful laboratory service improvement to benefit patients.

OBJECTIVE: To assess physicians' satisfaction and perspectives on the quality of services in clinical referral laboratories in Rwanda.

METHODS: A cross-sectional survey among physicians from four referral hospitals with closed-ended questionnaire and one general open-ended question. A five-point Likert scale rating was used to measure satisfaction. Descriptive, ordered logistic regression, and thematic analysis were used.

RESULTS: In total, 462 of 507 physicians (91% response rate) participated in the study. Overall mean satisfaction was 3.2 out of 5, and 36.2% of physicians were satisfied (satisfied and strongly satisfied) with laboratory services. In four service categories out of 17, the physicians' satisfaction was over 50%. The categories were: reliability of results (69.9%), adequacy of test reports (61.9%), laboratory staff availability (58.4%), and laboratory leadership responsiveness (51.3%). Lowest satisfaction was seen for routine test turnaround time (TAT) (19.3%), in-patient stat (urgent) test TAT (27%), communication of changes such as reagent stock out, new test (29%), and missing outpatient results (31%). Eighty-four percent answered that test TAT was not communicated, and 73.4% lacked virology diagnostics. Pediatricians, internists, and more experienced physicians were less satisfied. While ineffective communication, result delays, and service interruption were perceived as dissatisfying patterns, external audits were appreciated for improving laboratory services.

CONCLUSION: Availing continuously laboratory tests, timely result reporting, and effective communication between laboratories and clinicians would increase physicians' satisfaction and likely improve the quality of health care. Laboratory staff participation in clinical meetings and ward rounds with physicians may address most of the physicians' concerns.

Objectives: To explore challenges explaining the decrease in quality performance and suggest strategies to improve and sustain laboratory quality services.

Methods: Twenty key informants’ interviews from laboratory personnel were conducted in five laboratories. Four had previously shown a decrease in quality performance. Interviews were transcribed verbatim and analyzed using inductive thematic analysis.

Results: Two themes emerged: (1) insufficient coordination and follow-up system towards accreditation, where lack of coordination, follow-up, and audits explained the decrease in performance; (2) inadequate resource optimization, where insufficient knowledge in Laboratory Quality Management System (LQMS), ownership by laboratory workforce, and insufficient stakeholders’ communication contributed to low-quality performance.

Conclusions: The coordination, follow-up, and assessments of LQMS, in conjunction with training of laboratory workforce, would establish an institutional culture of continuous quality improvement (CQI) towards accreditation and sustainment of quality health care. To achieve CQI culture, routine gap checking and planning for improvement using a system approach is required.

Objectives: We investigated the quality system performance in Rwandan referral laboratories to determine their progress toward accreditation.

Methods: We conducted audits across five laboratories in 2017, using the Stepwise Laboratory Quality Improvement Process Towards Accreditation checklist. Laboratories were scored based on the World Health Organization grading scale (0-5 stars scale) and compared with earlier audits.

Results: Between 2012 and 2017, only one laboratory progressed (from four to five stars). Four of the five laboratories decreased to one (three laboratories) and zero (one laboratory) stars from four and three stars. Management reviews, evaluation, audits, documents, records, and identification of nonconformities showed a low performance.

Conclusions: Four of five laboratories are not moving toward accreditation. However, this target is still achievable by energizing responsibilities of stakeholders and monitoring and evaluation. This would be possible because of the ability that laboratories showed in earlier audits, coupled with existing health policy that enables sustainable quality health care in Rwanda.