Intimate Partner Violence Among Rwandan Women With HIV: A Cross-Sectional Study

ABSTRACT

In Rwanda, women have higher incidence of HIV and intimate partner violence (IPV). This study aimed to estimate the prevalence of IPV among women living with HIV (WWH) in Rwanda and measure the difference in psychological outcomes, demographic data, and HIV-related outcomes using a cross-sectional, descriptive, observational design. A convenience sample of 162 Rwandan WWH were purposefully recruited to participate. The study collected demographic data and data about IPV, depression, HIV-related stigma, coping, self-esteem, and hope. The prevalence of any form of IPV in the sample was 27% with psychological IPV being the most prevalent. Demographic data had no statistical significance with the prevalence of IPV. WWH who experienced IPV had higher HIV stigma, lower coping self-efficacy, lower self-esteem, and less hope and worse HIV psychological outcomes. Further studies are needed to look into the correlation between the two and interventions addressing IPV prevention.

Teaching family planning to nurse and midwife students: A constructivist grounded theory study

AIM

This study aimed to describe nurse/midwife educators' understanding and enactment of teaching family planning methods with nursing/midwifery students in educational programs in Rwanda. More precisely, the aim of this study was to generate a substantive theory that explains how nurse/midwife educators introduce family planning methods into their teaching practice to facilitate learning among nurse/midwife students in Rwanda.

BACKGROUND

High maternal mortality remains a global health issue. In 2017, approximately 295,000 women worldwide died from complications related to pregnancy or childbirth and 94% of these maternal deaths occurred in low-income countries. Evidence shows that family planning improves maternal health outcomes and significantly contributes to reducing maternal mortality. Low family planning uptake is partly attributed to inadequate education of healthcare providers to provide family planning services.

DESIGN

This study followed the constructivist grounded theory methodology articulated by Kathy Charmaz (2006; 2014).

METHODS

The primary data source was individual semi-structured interviews with 25 nurse/midwife educators recruited from all the schools/faculties/departments of nursing and midwifery in Rwanda, augmented with written documents related to family planning education in nursing/midwifery preservice programs.

RESULTS

The substantive Theory that emerged from the data analysis indicated that the process of teaching family planning in preservice nursing/midwifery education among nurse/midwife educators has three phases: preparing, facilitating and evaluating. Factors that had an impact on the process and actions that nurse/midwife educators undertook to address the challenges related to those factors were identified. The main influential factors that had a significant impact on nurse/midwife educators' ability to teach family planning are contextual factors and personal factors related to the nurse/midwife educators. The contextual factors included the availability of resources, student-teacher ratio, number of students in clinical placements and the time allocated to the family planning unit. The personal factors related to the nurse/midwife educators included knowledge, skills, confidence, attitude, beliefs and moral values toward family planning methods.

CONCLUSION

These study findings generated valuable knowledge that can guide the improvement of teaching family planning in preservice nursing/midwifery programs in Rwanda and other limited-resource countries and contexts. With the insights provided by this study, future research should investigate strategies to overcome highlighted barriers, increase nurse/midwife educators' expertise in teaching family planning and enhance the preparedness of nurse/midwife students on some family planning methods identified in this study.

A framework for capacity enhancement of Rwandan nurse educators and preceptors facilitating nursing students to learn pediatric pain management

INTRODUCTION

In low- and middle- income countries like Rwanda, children are most likely to suffer from painful and life-limiting conditions due to various factors predominant in these settings. Adequate pre-licensure pain management training can improve pain relief nursing practices. Educators and nurses in practice have a responsibility to teach the soon-to- be nurses for holistic competent nursing care of children, emphasizing the importance of and addressing child's suffering, yet inconsistencies were reported in what was taught regarding pediatric pain management from a theoretical perspective by nurse educators as compared to their counterparts in clinical settings in Rwanda.

DESIGN

This study applied a qualitative approach using group discussions based on nominal group technique (NGT) to develop and validate a conceptual framework supporting the capacity enhancement of nurse educators and preceptors facilitating students' learning about pediatric pain management in Rwanda.

METHODS

NGT meetings were conducted with academic nurses (n = 8), nurse clinicians (n = 4), and nursing students (n = 2) during a 2-day workshop to identify strategies, discuss the relevance of each strategy and to agree on key concepts of a framework for improving the ability of nurse educators and preceptors to teach PPM to nursing students. After four weeks another round of NGT meetings were done with nursing faculty (n = 6), academic nurse leaders (n = 3), nurse preceptors (n = 2), clinical nurse leaders (n = 2), a nurse leader from a regulatory body (n = 1), and nursing student (n = 1) to validate the developed framework.

FINDINGS

Four main strategies corresponding to the key concepts were mapped in a framework. Participants had a consensual agreement on the importance of the developed framework, they confirmed its completeness and practicality. In addition, participants found that the developed framework is logical, and confirmed that it is applicable for its purpose.

CONCLUSION

The developed framework presents an opportunity to respond to the gaps in nursing pain education in the context of limited resources settings such as Rwanda. It can also be applied in nursing practice and nursing research, aligning with the need of improving the quality of care of suffering children. Furthermore, the framework can be adapted and utilized to meet the needs of healthcare professionals other than nurses.

CLINICAL RELEVANCE

Strategies are suggested to improve the ability of nurse educators and preceptors in clinical settings to facilitate the acquisition of pediatric pain management competencies by the next generation of nurses. Future Rwandan nurses could then use the competencies acquired to provide optimal health care to children with pain in the best way possible during their practices.

Sexuality and Sexual and Reproductive Health Depiction in Social Media: Content Analysis of Kinyarwanda YouTube Channels

BACKGROUND

Social media platforms such as YouTube can be used to educate people of reproductive age about healthy and nonrisky sexual and reproductive health (SRH) practices and behaviors. However, there is a paucity of evidence to ascertain the authenticity of sexuality and SRH content on Kinyarwanda YouTube, making it difficult to determine the extent to which these topics are covered, the characteristics of available videos, and the themes covered by these videos.

OBJECTIVE

The aims of this study were (1) to determine the extent to which YouTube channels in Kinyarwanda-language videos address sexuality and SRH issues, identify the general characteristics of the available videos (type of video, when published, intention for the audience, and content focus), and the aspects of sexuality and SRH covered; and (2) to identify the themes covered by retrieved Kinyarwanda videos, and the extent to which the channels have been used to communicate issues of sexuality and SRH during the COVID-19 pandemic.

METHODS

Using a content analysis approach, we searched Kinyarwanda YouTube channels to analyze videos about sexuality and SRH. The adopted framework for data collection from social media platforms builds on three key steps: (1) development, (2) application, and (3) assessment of search filters. To be included, an audio and/or visual video had to be in Kinyarwanda and the video had to be directed to the general public. Descriptive statistics (frequency and percentages) were computed to characterize the basic characteristics of retrieved channels, portrayal of the videos, and presentation of sexuality and SRH themes that emerged from retrieved videos. Further analysis involved cross-tabulations to explore associations between the focus of the channel and the date when the channel was opened and the focus of the channel and who was involved in the video.

RESULTS

The YouTube search retrieved 21,506 videos that tackled sexuality and SRH topics. During the COVID-19 pandemic, there was a 4-fold increase (from 7.2% to 30.6%) in channels that solely focused on sexually explicit content. The majority of the 1369 retrieved channels (n=1150, 84.0%) tackled the topic of sexuality, with sexually explicit content predominantly found in the majority of these videos (n=1082, 79%), and only 16% (n=287) of the videos covered SRH topics.

CONCLUSIONS

This is the first study to analyze the use of YouTube in communicating about sexuality and SRH in the Kinyarwanda language. This study relied on videos that appeared online. Further research should gather information about who accesses the videos, and how channel owners and individuals involved in the videos perceive the impact of their videos on the Rwandan community's sexuality and SRH.

Dehumanizing language, motherhood in the context of HIV, and overcoming HIV stigma - the voices of Rwandan women with HIV: A focus group study

BACKGROUND

Stigma is an underlying cause of health inequities, and a major barrier to HIV prevention, care, and treatment. Experiences of HIV stigma have been shown to reduce engagement in care across the HIV care continuum, from testing and diagnosis to long-term retention in care and anti-retroviral therapy adherence. In Rwanda, approximately 130,000 women are living with HIV, representing a prevalence rate (3.7%) which is substantially higher than Rwandan men (2.2%). Both the national Rwanda and City of Kigali HIV and AIDS strategic plans identify stigma as a key concern for reducing the burden of HIV.

OBJECTIVES

The first objective of this study was to understand the sources of HIV-related stigma among women living with HIV in Rwanda. The second objective was to understand the cultural, linguistic, and contextual context of HIV-related stigma and the intersection of HIV-related stigma to the HIV care continuum (engagement in care, medication/treatment adherence) among women with HIV in Rwanda.

DESIGN

This study used a cross-sectional, qualitative design.

SETTING AND PARTICIPANTS

Three-three women from urban and rural settings in Rwanda were recruited from public HIV treatment and care centers to participate in this study.

METHOD

Focus groups discussions, guided by a structured interview guide, were used to collect qualitative data. Framework analysis was used to analyze the data, which was collected during July 2018.

RESULTS

The participants in this study highlighted that Rwandan women with HIV experience all forms of stigma - enacted, anticipated, perceived, and internalized - associated with HIV as well as structural stigma. Further, three major themes - dehumanizing language, importance of motherhood in the context of HIV, and overcoming HIV stigma - emerged from the data.

CONCLUSION

The results of this study are among the few to give voice and perspective to the stigma experiences of Rwandan women with HIV. The women with HIV participating in this study shed light on the pervasive and culturally constructed effects of stigma that continue to exist. Further, the findings from this study highlighted the significant intersection of the role dehumanizing language experienced by Rwandan women with HIV. Additionally, the intersectional identities of being a woman with HIV and a mother and their relationship to societal and cultural norms and expectations must be considered concurrently. Finally, the beneficial effects of support groups was identified as key in helping Rwandan women with HIV to accept self.

Exploring factors affecting the facilitation of nursing students to learn paediatric pain management in Rwanda: A descriptive qualitative study

Nurse educators and nurse preceptors play a fundamental role in facilitating nursing students' acquisition and utilization of professional competencies. Previous studies about key elements for teaching and learning about pain in nursing education programs include students' personal characteristics and previous experiences; educators' knowledge, skills, and beliefs; learners' exposure to leaders in pain education; and curricular pain content and delivery approaches. These studies were mainly carried out in developed countries, with a context of educational and health care systems different from those of developing countries. The current study explores academics', clinical nurse preceptors', and nursing students' perceptions about factors influencing the facilitation of nursing students' competency for paediatric pain management in Rwanda. A qualitative descriptive exploratory design was used in this study that utilized in-depth interviews with six nurse educators and eight nurse preceptors, and focus group discussions with nineteen senior year nursing students. The study setting included five sites: two academic institutions and three clinical settings. Narratives from participants were transcribed verbatim and analysed using thematic analysis. The analysis yielded six themes describing factors that affected the facilitation of students' learning about paediatric pain management. The themes included student motivation, facilitators' attributes, collaboration between academics and clinicians, nurses' limited autonomy for decision-making regarding PPM practices, shortage of human and material resources, and educational qualification. Knowing these factors is essential as it provides an opportunity to design targeted interventions aimed to enhance the capacity of nurse educators and clinical nurse preceptors involved in teaching nursing students about paediatric pain management.

Nurses' and nurse educators' experiences of a Pediatric Nursing Continuing Professional Development program in Rwanda

OBJECTIVES

In 2016, a Pediatric Nursing Continuing Professional Development (PNCPD) program was created and implemented in Kigali, Rwanda, through the Training, Support, and Access Model (TSAM) for Maternal, Newborn, and Child Health (MNCH). This partnership project between Canada and Rwanda provided pediatric nursing education to forty-one Rwandan nurses and nurse educators in 2018 and 2019. The objective of this research study was to explore the experiences of nurses and nurse educators applying pediatric knowledge and skills to academic and clinical settings after participating in the PNCPD program.

METHODS

This study was situated within an interpretive descriptive perspective to explore the ways in which knowledge gained during the PNCPD program in Rwanda was applied by nurses and nurse educators in their nursing practice, both academically and clinically. Data was collected through individual interviews. Inductive content analysis was used for data analysis.

RESULTS

The analysis of the interviews resulted in the emergence of five themes: Transformations in Pediatric Nursing Practice, Knowledge Sharing, Relationship-Based Nursing, Barriers and Facilitators to Knowledge Implementation, and Scaling-up PNCPD within the Health System.

CONCLUSIONS

The results of this study have the potential to inform positive changes to child health care in Rwanda, including scaling up pediatric nursing education to other areas of the healthcare system.

Double Jeopardy: Young adult mental and physical health outcomes following conception via genocidal rape during the 1994 genocide against the Tutsi in Rwanda

Rwandans conceived by rape during the 1994 genocide against the Tutsi have endured a violent beginning and a troubled childhood. Given compelling evidence of the influence of prenatal environments and adverse childhood experiences (ACEs) on future health, these individuals are at high risk of poor mental and physical health outcomes. The purpose of the study was to characterize mental and physical health outcomes in young adults who were exposed prenatally to maternal stress due to the genocide in general and those conceived by genocidal rape, and to determine whether ACEs compound these effects. Ninety-one 24-year-old Rwandans - 30 conceived by genocidal rape, 31 born of genocide survivors not raped, and a control group of 30 born of women with neither exposure - completed the Adverse Childhood Experiences International Questionnaire and measures of multiple physical and mental health characteristics. Data were collected from March 7 to April 6, 2019. Findings demonstrated that 1) individuals conceived during the genocide had poorer mental function (p = 0.002) and higher scores in post-traumatic stress disorder (PTSD), anxiety, depression, physical function, pain intensity, and sleep disturbance compared to young adults who were not exposed to genocide (all p < 0.033); 2) individuals conceived by genocidal rape reported more depression, PTSD, and pain interference compared to those prenatally exposed to maternal genocide stress only (all p < 0.008); and 3) among the group conceived via genocidal rape, the effects of prenatal exposures on depression, physical function, pain intensity and pain interference were exacerbated by ACEs (all p < 0.041). Being conceived during genocide, especially through genocidal rape, is associated with poor adult physical and mental health. The role of ACEs in exacerbating prenatal genocide exposure highlights opportunities for interventions to reduce these effects.

Blended teaching and learning methods in nursing and midwifery education: A scoping review of the literature

Background: Blended learning (BL) is defined as the combination of both traditional face-to-face learning and synchronous or asynchronous e-learning approaches. The aim of this scoping review was to explore the literature to obtain a broad understanding of the use of BLin nursing and midwifery education in general, in Sub-Saharan Africa (SSA), and in particular Rwanda.Methods: The literature published between 2010 and 2019 were reviewed from six electronic databases using keywords including blended learning, nursing education, midwifery education, higher education, SSA, and Rwanda. Arksey and O'Malley's framework was used in this review.Results: The initial search identified 1,283 records. Eleven articles were selected for this review after the application of predetermined inclusion criteria. Almost all reviewed articles indicated that the integration of BLmethods improved the quality of nursing and midwifery education in general, and in SSAcountries including Rwanda.Conclusions: Initial research in this area highlights that moving from traditional classroom-delivered programs to the BLapproach is feasible and can promote the quality of nursing and midwifery standards of education. This scoping review highlights a paucity of research on BL in nursing and midwifery education, particularly in SSAcountries. Keywords: Blended learning, nursing and midwifery education, SSA, Rwanda

Facilitation of nursing students' competency acquisition for paediatric pain management in low- and middle-income countries: a scoping review

Objective: To elucidate evidence regarding nurse educators' and preceptors' capacity to facilitate students' learning about paediatric pain management (PPM) in low- and middle-income countries(LMICs).Methods: The five-stage framework by Arksey and O'Malley guided this review. Studies published in English between January 2010 and April 2020 were searched using EBSCO Host/ ScienceDirect, CINAHL, MEDLINE, PUBMED and Scopus. Of 300 papers identified through the search strategy 27 primary research articles were retained: quantitative (n=18), qualitative (n=8) and mixed-methods (n=1).Results: Knowledge deficiency and inappropriate attitudes toward PPM, lack of autonomy in decisionmaking, scarcity of resources and cultural misconception regarding pain in children were hindering the effective PPM in LMICs. Strategies including nursing curricula review, continuous in-service training, access to resources and the leadership support are required to optimise effective PPM and improve students' facilitation for learning about PPM.Conclusion: Further research is required as a body of evidence to support the development of a framework for capacity enhancement of nurse educators and nurse preceptors who facilitate nursing students acquiring competency for PPM in LMICs. Keywords: Pain management education, Children, Scoping review, Low- and middle- income countries

Early routine amniotomy: an unnecessary procedure

Early routine amniotomy, also known as artificial rupture of the amniotic membrane, is one of the procedures used to induce and accelerate labour before cervical dilation reaches four centimeters. Because of its benefits and risks, there are at least two schools of thought about this controversial issue. The purpose of this paper is to argue against early routine amniotomy as an unnecessary procedure that can have drastic and unintended outcomes associated with the labour process, the fetus, and the mother. This commentary paper articulates that early routine amniotomy is a questionable procedure because its risks outweigh its benefits. Therefore, routine early amniotomy should be discouraged among obstetrical procedures. Keywords: Amniotomy, artificial rupture of membrane, routine, labour, process

Nursing Theory in the Quest for the Sustainable Development Goals

The 17 United Nations Sustainable Development Goals (SDG) are intended to promote a safe, healthy, and equitable world by the year 2030. Nurses are at the forefront of realizing the 2030 agenda through concerned citizenship and professional leadership. Nursing theory informs knowledge development and theory-guided practice essential for nurses working in all domains and in all nations. Although all extant nursing theories are relevant, a select few are discussed in detail to make explicit the links between theory and SDG realization. Middle-range theories are also valuable in helping to contextualize nursing practice through the lens of the SDGs. The SDGs address five themes - People, Planet, Peace, Prosperity, and Partnership - and theory remains vital to ensure nurses working in all settings are equipped to meet the needs of humanity and the world, now and in the future.

The Impact of COVID-19 Pandemic on Maternal and Child Health Services in Rwanda

No Abstract.

Implications of COVID-19 Lockdown on Child Preparedness among Rwandan Families

The world is currently facing the fatal viral pandemic called coronavirus disease 2019 (COVID-19), earlier named 2019-novel coronavirus (2019- nCoV). Every country of the world keeps responding to the challenges posed by covid-19 in all aspects of human endeavour with high demand and burden on health care. The report of the first case in Rwanda on 14th March 2020 was accompanied by actions to drive control measures by the government of Rwanda importantly to prevent the spread of COVID-19. Those measures included education on personal preventive behaviours, social distancing and restricting the movement of people locally, nationally and internationally resulting to lockdown that allowed only essential services. Lockdown has particularly affected Rwandan families with pregnant mothers in the context of childbirth preparation in different aspects.  This review paper articulates the possible various dimensions of influence of the COVID-19 lockdown on birth preparedness by families and the possible maternal and neonatal health adverse outcomes that may be associated. This is with the intention of helping health care providers and other stakeholders anticipate, track and prepare for appropriate mitigation to reduce maternal-neonatal morbidity and mortality.   French title: Implications du verrouillage de COVID-19 sur la préparation des enfants dans les familles RwandaisesLe monde est actuellement confronté à la pandémie virale mortelle appelée maladie à coronavirus 2019 (COVID-19), précédemment appelée 2019-nouveau coronavirus (2019-nCoV). Chaque pays du monde continue de répondre aux défis posés par le Covid-19 dans tous les aspects de l'activité humaine avec une forte demande et un fardeau sur les soins de santé. Le rapport du premier cas au Rwanda le 14e mars 2020 a été accompagné d'actions à conduire des mesures de contrôle par le gouvernement du Rwanda important pour prévenir la propagation de Covid-19. Ces mesures comprenaient une éducation sur les comportements personnels de prévention, la distanciation sociale et la restriction de la circulation des personnes aux niveaux local, national et international, entraînant un verrouillage qui n'autorisait que les services essentiels. Le verrouillage a particulièrement affecté les familles Rwandaises de mères enceintes dans le cadre de la préparation à l'accouchement sous différents aspects. Cet article de synthèse articule les différentes dimensions possibles de l'influence du verrouillage du COVID-19 sur la préparation à la naissance des familles et les éventuels effets indésirables sur la santé maternelle et néonatale qui peuvent être associés. Ceci dans le but d'aider les prestataires de soins de santé et les autres parties prenantes à anticiper, suivre et préparer des mesures d'atténuation appropriées pour réduire la morbidité et la mortalité materné-néonatales.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda

BACKGROUND

The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda.

METHODS

The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors.

RESULTS

In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions.

CONCLUSION

The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

Genocide Rape Trauma: A Conceptual Framework for Understanding the Psychological Suffering of Rwandan Survivors

In 1994, the Rwandan genocide claimed the lives of approximately 1 million Tutsi and moderate Hutu citizens. Systematic rape was a strategic component of the Hutu extremist plan to eradicate the Tutsi minority population. This involved collective and repeated sexual assaults with brutal violence, public humiliation, and torture. This article maps the ongoing psychological impact on Rwandan genocide rape survivors and identifies implications for international nursing practice. The research formalizes their narratives, identifying a number of interconnected elements that combine to produce myriad forms of chronic psychological suffering in the Rwandan context. This work in turn reveals the specific needs of these survivors that may be addressed by nursing. It allows nurses, as experts in managing the human responses to health and illness, to develop a more complete understanding of psychological suffering as it pertains to vulnerable populations during and in the wake of extreme social conflict. This clarifies the roles of nurse educators, clinicians, and policy advocates as key agents in providing genocide rape survivors with the resources and expertise needed to effectively manage their ongoing trauma.

Building Nursing and Midwifery Capacity Through Rwanda's Human Resources for Health Program

Global disparities in the quantity, distribution, and skills of health workers worldwide pose a threat to attainment of the Sustainable Development Goals by 2030 and deepens already existing global health inequities. Rwanda and other low-resource countries face a critical shortage of health professionals, particularly nurses and midwives. This article describes the Human Resources for Health (HRH) Program in Rwanda, a collaboration between the Ministry of Health of Rwanda and a U.S. consortium of academic institutions. The ultimate goal of the HRH Program is to strengthen health service delivery and to achieve health equity for the poor. The aim of this article is to highlight the HRH nursing and midwifery contributions to capacity building in academic and clinical educational programs throughout Rwanda. International academic partnerships need to align with the priorities of the host country, integrate the strengths of available resources, and encourage a collaborative environment of cultural humility and self-awareness for all participants.

Nephrology Nursing in Rwanda: Creating the Future Through Education and Organizational Partnership

The Human Resources for Health Program was launched in Rwanda in 2012 as a sevenyear initiative to improve healthcare services and decrease overall dependence on foreign aid. In partnership between U.S. academic institutions and Rwandan education affiliates, nursing resources have become primarily centered on the design and implementation of Rwanda's first Masters of Science in Nursing (MScN) Program at the School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali. The nephrology track consists of seven students with a wealth of clinical and educational experience who will receive the training needed to become advanced, ethical, and capable leaders in the nephrology nursing field. Faculty member William Rosa collaborated with the American Nephrology Nurses Association (ANNA) to provide these students with the online community, continuing education, practice standards, and journal access required to be proficient as graduate nurses through the donations of virtual memberships and copies of necessary texts. This is the University of Rwanda's MScN Nephrology Track story.

The "treatment gap" in global mental health reconsidered: sociotherapy for collective trauma in Rwanda

BACKGROUND

The "treatment gap" (TG) for mental disorders refers to the difference that exists between the number of people who need care and those who receive care. The concept is strongly promoted by the World Health Organization and widely used in the context of low- and middle-income countries. Although accepting the many demonstrable benefits that flow from this approach, it is important to critically reflect on the limitations of the concept of the TG and its implications for building capacity for mental health services in Rwanda.

OBJECTIVE

The article highlights concerns that the evidence base for mental health interventions is not globally valid, and problematizes the preponderance of psychiatric approaches in international guidelines for mental health. Specifically, the risk of medicalization of social problems and the limited way in which "community" has been conceptualized in global mental health discourses are addressed. Rather than being used as a method for increasing economic efficiency (i.e., reducing healthcare costs), "community" should be promoted as a means of harnessing collective strengths and resources to help promote mental well-being. This may be particularly beneficial for contexts, like Rwanda, where community life has been disrupted by collective violence, and the resulting social isolation constitutes an important determinant of mental distress.

CONCLUSIONS

Moving forward there is a need to consider alternative paradigms where individual distress is understood as a symptom of social distress, which extends beyond the more individually oriented TG paradigm. Sociotherapy, an intervention used in Rwanda over the past 10 years, is presented as an example of how communities of support can be built to promote mental health and psychosocial well-being.