Care In Rwanda Research Articles

The path to sustainable cardiac surgery in Rwanda: analysis of costs for consumables used during cardiac surgery for a non-governmental organization

BackgroundUntil local healthcare infrastructure is strengthened, cardiac surgical care in low- and middle-income countries is often provided by non-governmental organizations by way of visiting healthcare teams. This is generally considered to be a cost-effective alternative to transporting patients to high income countries for surgical care, but the costs of cardiac surgery consumables under this model are poorly understood. Our objective was to identify the per-patient cost of cardiac surgery consumables used in single and double valve replacements performed by a non-governmental organization in Rwanda.MethodsFinancial data from 2020 were collected from Team Heart, a non-governmental organization that supports cardiac surgical care in Rwanda. A comprehensive list of consumables was generated, including surgical, perfusion, anesthesia, and inpatient supplies and medications. Acknowledging the variability in perioperative needs, the quantities of consumables were calculated from an average of six patients who underwent single or double-valve replacement in 2020. Total costs were calculated by multiplying purchasing price by average quantity per patient. Costs absorbed by the local hospital were excluded from the calculations.ResultsThe total cost per patient was estimated at $9,450. Surgical supplies comprised the majority of costs ($6,140 per patient), with the most substantial cost being that of replacement valves ($3,500 per valve), followed by surgical supplies ($1,590 per patient).ConclusionsThis preliminary analysis identifies a cost of just over $9,000 per patient for consumables used in cardiac valve surgery in Rwanda, which is lower than the estimated costs of transporting patients to centers in high income countries. This work highlights the relative cost effectiveness of cardiac surgical care in low- and middle- income countries under this model and will be instrumental in guiding the allocation of local and international resources in the future.

Strategies to Sustain Interprofessional Collaboration in Emergency Obstetric and Neonatal Care in Rwanda: Perspectives of Healthcare Professionals and Hospital Managers

Strategies to Sustain Interprofessional Collaboration in Emergency Obstetric and Neonatal Care in Rwanda: Perspectives of Healthcare Professionals and Hospital Managers

Factors Influencing Data Quality in Electronic Health Record Systems in 50 Health Facilities in Rwanda and the Role of Clinical Alerts: Cross-Sectional Observational Study.

Electronic health records (EHRs) play an increasingly important role in delivering HIV care in low- and middle-income countries. The data collected are used for direct clinical care, quality improvement, program monitoring, public health interventions, and research. Despite widespread EHR use for HIV care in African countries, challenges remain, especially in collecting high-quality data. We aimed to assess data completeness, accuracy, and timeliness compared to paper-based records, and factors influencing data quality in a large-scale EHR deployment in Rwanda. We randomly selected 50 health facilities (HFs) using OpenMRS, an EHR system that supports HIV care in Rwanda, and performed a data quality evaluation. All HFs were part of a larger randomized controlled trial, with 25 HFs receiving an enhanced EHR with clinical decision support systems. Trained data collectors visited the 50 HFs to collect 28 variables from the paper charts and the EHR system using the Open Data Kit app. We measured data completeness, timeliness, and the degree of matching of the data in paper and EHR records, and calculated concordance scores. Factors potentially affecting data quality were drawn from a previous survey of users in the 50 HFs. We randomly selected 3467 patient records, reviewing both paper and EHR copies (194,152 total data items). Data completeness was >85% threshold for all data elements except viral load (VL) results, second-line, and third-line drug regimens. Matching scores for data values were close to or >85% threshold, except for dates, particularly for drug pickups and VL. The mean data concordance was 10.2 (SD 1.28) for 15 (68%) variables. HF and user factors (eg, years of EHR use, technology experience, EHR availability and uptime, and intervention status) were tested for correlation with data quality measures. EHR system availability and uptime was positively correlated with concordance, whereas users' experience with technology was negatively correlated with concordance. The alerts for missing VL results implemented at 11 intervention HFs showed clear evidence of improving timeliness and completeness of initially low matching of VL results in the EHRs and paper records (11.9%-26.7%; P<.001). Similar effects were seen on the completeness of the recording of medication pickups (18.7%-32.6%; P<.001). The EHR records in the 50 HFs generally had high levels of completeness except for VL results. Matching results were close to or >85% threshold for nondate variables. Higher EHR stability and uptime, and alerts for entering VL both strongly improved data quality. Most data were considered fit for purpose, but more regular data quality assessments, training, and technical improvements in EHR forms, data reports, and alerts are recommended. The application of quality improvement techniques described in this study should benefit a wide range of HFs and data uses for clinical care, public health, and disease surveillance.

The current state, advancements and challenges of neurosurgical care in Rwanda - a short report.

The current state, advancements and challenges of neurosurgical care in Rwanda - a short report.

Enhancing clinical reasoning for management of non-communicable diseases: virtual patient cases as a learning strategy for nurses in primary healthcare centers: a pre-post study design

BackgroundIn Rwanda, nurses manage all primary care at health centres, and therefore are their clinical reasoning skills important. In this study, a web-based software that allows the creation of virtual patient cases (VP cases) has been used for studying the possibility of using VP cases for the continuous professional development of nurses in primary health care in Rwanda. Previous studies in pre-service education have linked VP cases with the enhancement of clinical reasoning, a critical competence for nurses. This study investigated the feasibility of continuous professional development through VP cases to further train in-service nurses in clinical reasoning.MethodThe study used a pre-post test design. Initially, seventy-six participants completed a questionnaire as part of the pre-test phase, subsequently invited to engage with all four VP cases, and finally responded to the post-test questionnaire evaluating clinical reasoning skills. Fifty-six participants successfully completed the entire study process and were considered in the analysis. The primary outcomes of this study were evaluated using a paired t-test for the statistical analysis.ResultsThe results show that the mean score of clinical reasoning increased significantly from the pre-test to the post-test for all four illness areas (p < 0.001). The study findings showed no statistically significant difference in participants’ scores based on demographic factors, including whether they worked in urban or rural areas. Conclusion and recommendationUtilizing VP cases appears to significantly enhance the continuous professional development of nurses, fostering a deliberate learning process that enables them to reflect on how they manage cases and, in turn, refine their clinical reasoning skills. This study strongly recommends incorporating VP cases in the continuous professional development of nurses at the primary health level (health centers). This is especially pertinent in a context where nurses are required to perform diagnostic processes similar to those employed by physicians.

Access to continuous professional development for capacity building among nurses and midwives providing emergency obstetric and neonatal care in Rwanda

BackgroundNurses and midwives are at the forefront of the provision of Emergency Obstetric and Neonatal Care (EmONC) and Continuous Professional Development (CPD) is crucial to provide them with competencies they need to provide quality services. This research aimed to assess uptake and accessibility of midwives and nurses to CPD and determine their knowledge and skills gaps in key competencies of EmONC to inform the CPD programming.MethodsThe study applied a quantitative, cross-sectional, and descriptive research methodology. Using a random selection, forty (40) health facilities (HFs) were selected out of 445 HFs that performed at least 20 deliveries per month from July 1st, 2020 to June 30th, 2021 in Rwanda. Questionnaires were used to collect data on updates of CPD, knowledge on EmONC and delivery methods to accessCPD. Data was analyzed using IBM SPSS statistics 27 software.ResultsNurses and midwives are required by the Rwandan midwifery regulatory body to complete at least 60 CPD credits before license renewal. However, the study findings revealed that most health care providers (HCPs) have not been trained on EmONC after graduation from their formal education. Results indicated that HCPs who had acquired less than 60 CPD credits related to EmONC training were 79.9% overall, 56.3% in hospitals, 82.2% at health centres and 100% at the health post levels. This resulted in skills and knowledge gaps in management of Pre/Eclampsia, Postpartum Hemorrhage and essential newborn care. The most common method to access CPD credits included workshops (43.6%) and online training (34.5%). Majority of HCPs noted that it was difficult to achieve the required CPD credits (57.0%).ConclusionThe findings from this study revealed a low uptake of critical EmONC training by nurses and midwives in the form of CPD. The study suggests a need to integrate EmONC into the health workforce capacity building plan at all levels and to make such training systematic and available in multiple and easily accessible formats.Implication on nursing and midwifery policyFindings will inform the revision of policies and strategies to improve CPD towards accelerating capacity for the reduction of preventable maternal and perinatal deaths as well as reducing maternal disabilities in Rwanda.

Strategies for facilitating and sustaining respectful maternity care in Rwanda: an expert review

Strategies for facilitating and sustaining respectful maternity care in Rwanda: an expert review

A Comparative Gender Analysis of Injury Characteristics, Treatments and Outcomes among Persons Seeking Emergency Care in Kigali, Rwanda

In high-income nations, gender has been associated with injury characteristics. This study evaluated injury epidemiology and care based on gender at the Centre Hospitalier Universitaire de Kigali in Rwanda. Patients presenting to the emergency department with acute injuries were prospectively enrolled from 27 January–28 June 2020, and descriptive statistics were performed with comparisons between males and females. Of 601 patients, 25.6% were female and 74.4% were male. There were gender differences in the mechanism of injury, with females more likely to be injured in falls (43.5% versus 23.0%, p = 0.001); meanwhile, males were more likely to suffer road traffic accidents (52.6% versus 39.6%, p = 0.006). The severity of injury was similar between genders based on the mean Kampala Trauma Score (14.4 versus 14.7, p = 0.09). Females were more likely to have been transported by prehospital services (87.7% versus 72.9%, p = 0.001), and less likely to receive acute treatment during the first six hours of care (67.5% versus 78.1%, p = 0.009). There was no significant difference in mortality between females and males (2.0% versus 1.3%, p = 0.568). This study highlights differences in the epidemiology and care between males and females presenting for emergency injury care in Rwanda. These findings can inform future research and developments in gender-centered healthcare delivery.

Financial Toxicity: Unveiling the Burden of Cancer Care on Patients in Rwanda.

Cancer is a major public health problem in Rwanda and other low- and middle-income countries (LMICs). While there have been some improvements in access to cancer treatment, the cost of care has increased, leading to financial toxicity and treatment barriers for many patients. This study explores the financial toxicity of cancer care in Rwanda. This prospective cross-sectional study was conducted at 3 referral hospitals in Rwanda, which deliver most of the country's cancer care. Data were collected over 6 months from June 1 to December 1, 2022 by trained research assistants (RAs) using a modified validated data collection tool. RAs interviewed consecutive eligible patients with breast cancer, cervical cancer, colorectal cancer, Hodgkin's and non-Hodgkin's lymphoma who were on active systemic therapy. The study aimed to identify sources of financial burden. Data were analyzed using descriptive statistics. 239 patients were included; 75% (n = 180/239) were female and mean age was 51 years. Breast, cervix, and colorectal cancers were the most common diagnoses (42%, 100/239; 24%, 58/239; and 24%, 57/239, respectively) and 54% (n = 129/239) were diagnosed with advanced stage (stages III-IV). Financial burden was high; 44% (n = 106/239) of respondents sold property, 29% (n = 70/239) asked for charity from public, family, or friends, and 16% (n = 37/239) took loans with interest to fund cancer treatment. Despite health insurance which covers many elements of cancer care, a substantial proportion of patients on anti-cancer treatment in Rwanda experience major financial toxicity. Novel health financing solutions are needed to ensure accessible and affordable cancer care.

Challenges and opportunities to improve efficiency and quality of prehospital emergency care using an mHealth platform: Qualitative study in Rwanda

IntroductionPrompt, high-quality pre-hospital emergency medical services (EMS) can significantly reduce morbidity and mortality. The goal of this study was to identify factors that compromise efficiency and quality of pre-hospital emergency care in Rwanda, and explore the opportunities for a mobile health (mHealth) tool to address these challenges. MethodsIn-depth interviews were conducted with 21 individuals representing four stakeholder groups: EMS dispatch staff, ambulance staff, hospital staff, and policymakers. A semi-structured interview guide explored participants’ perspectives on all aspects of the pre-hospital emergency care continuum, from receiving a call at dispatch to hospital handover. Participants were asked how the current system could be improved, and the potential utility of an mHealth tool to address existing challenges. Interviews were audio-recorded, and transcripts were thematically analyzed using NVivo. ResultsStakeholders identified factors that compromise the efficiency and quality of care across the prehospital emergency care continuum: triage at dispatch, dispatching the ambulance, locating the emergency, coordinating patient care at scene, preparing the receiving hospital, and patient handover to the hospital. They identified four areas where an mHealth tool could improve care: efficient location of the emergency, streamline communication for decision making, documentation with real-time communication, and routine data for quality improvement. While stakeholders identified advantages of an mHealth tool, they also mentioned challenges that would need to be addressed, namely: limited internet bandwidth, capacity to maintain and update software, and risks of data security breaches that could lead to stolen or lost data. ConclusionDespite the success of Rwanda's EMS system, this study highlights factors across the care continuum that could compromise quality and efficiency of prehospital emergency care. Mobile health tools hold great promise to address these challenges, but contextual issues need to be considered to ensure sustainability of use.

Barriers to equitable access to quality trauma care in Rwanda: a qualitative study

ObjectivesUsing the ‘Four Delay’ framework, our study aimed to identify and explore barriers to accessing quality injury care from the injured patients’, caregivers’ and community leaders’ perspectives.DesignA qualitative study assessing...

A cross-sectional analysis of the impact of health insurance on the use of health care in Rwanda

Although the policy in Rwanda aims at ensuring quality healthcare, a portion of the Rwandan population still does not have access to it due to the lack of health insurance. This study investigates the impact of health insurance on healthcare utilization in all 30 administrative districts of Rwanda, using secondary data from the 5th Integrated Household Living Conditions Survey (EICV 5) in Rwanda, with a total of 14,580 households. A logistic regression model was used to evaluate the effects of health insurance on healthcare utilization, and a decision tree model was adopted to categorize districts based on the use of health services.This study has made a novel contribution to the existing research by classifying districts based on similarities in the use of health care services, regarding households with or without health insurance. The results showed a significant age effect on the use of health care services for household heads with an age range of 56–65, a significant increase was observed with an adjusted odds ratio of AO = 1.308, (95% CI: 1.044–1.639). It was the same for the household heads whose age range is 66–75 with an adjusted odds ratio of A0 = 1.589 with (95% CI: 1.244–2.028) and those aged 76 and older with an adjusted odds ratio of AO = 1.524, with (95% CI: 1.170–1.985). Households with health insurance interacted with districts (A0 = 2.76) increased health service use threefold compared to households without health insurance, female-headed households increased health service use (AO = 1.423, 95% CI:1.293–1.566) 1.4-fold compared to male-headed households, while households in the third quintile (AO = 1.198, 95% CI: 1.035–1.385) used health services 1.2 times compared to those in the first quintile; households in the fourth quintile (AO = 1.307, 95% CI: 1.134–1.506) and in the fifth quintile (AO = 1.307, 95% CI: 1.136 1.504) used health services 1.3 times compared to those in the first quintile. Similarly, for the households located in the main district group 4 variable had an odds ratio of 1.386 with (95% CI: 1.242–1.547), indicating that the households located in the main district group 4 use the health care services 1.4 times higher compared to those located in Ruhango district.Households in Rwanda who lack health insurance do not utilize health services to their full capacity, which has a negative influence on the wellbeing of the country’s population.The researchers recommend that future policies target households in rural areas with an elderly head of household and those without health insurance that have a low usage of health care services in Rwanda. They also recommend that health insurance fees are reduced in order to increase health coverage rate as recommended by the World Health Organization.

Interprofessional collaboration experience among healthcare professionals providing emergency obstetric and neonatal care in Rwanda. A qualitative descriptive case study

IntroductionInterprofessional collaboration (IPC) is essential in all health care services delivery including maternity care, particularly in emergency obstetric and neonatal care (EmONC). Ideally, the obstetric team would work together in dynamic and complex situations to deliver quality care and achieve optimal patient outcomes. The current study explored IPC experience among healthcare providers working in maternity service and providing EmONC in Rwanda. The purpose was to understand from clinicians’ perspectives the benefits and barriers to achieving effective collaboration while managing EmONC. MethodA qualitative descriptive case study was conducted in five district hospitals in the Northern province of Rwanda. The study involved 25 healthcare professionals, including nurses, midwives, medical doctors, and non-physician anesthetists working in maternity units from selected district hospitals. FindingsParticipants highlighted several benefits of effective IPC, such as reducing maternal and neonatal mortality and morbidity, reducing stress, and better-quality service delivery in general. However, participants expressed challenges to successful IPC related to power relation issues affecting communication and other IPC competencies. Also, a stressful work environment characterized by a shortage of staff and lack of necessary resources was identified as a barrier to effective IPC. Conclusionand recommendations: IPC is an important aspect to consider in delivering quality EmONC since failure in effective IPC can lead to compromised patients’ outcomes and increased stress among healthcare providers. Therefore, it is imperative that policymakers, health professional educators, and clinicians identify strategies to improve interprofessional working relationships and contribute to quality obstetric and neonatal care in order to achieve the best maternal and neonatal-related sustainable development goals in Rwanda.

Comparison of Injury Epidemiology and Treatments by Gender Among Persons Seeking Emergent Care in Kigali, Rwanda

Introduction:Variations in the incidence and patterns of injuries exist between genders which may impact treatments and outcomes. The study aimed to describe the epidemiology, treatments, and outcomes based on the gender of persons presenting with injuries to an Emergency Department (ED) in Kigali, Rwanda.Method:This was a secondary analysis of a prospective cross-sectional study conducted in January-June 2021 at the Centre Hospitalier Universitaire de Kigali ED. Descriptive statistics were performed and variable comparisons based on binary gender self-designation (male or female) were conducted.Results:A total of 601 patients were included in the analysis of whom 25.6% were female and 74.4% were male. Gender differences were found in the mechanism of injury with females more likely to be injured via falls (43.5% versus 23.0%, p=0.001), while males were more likely to be in a road traffic accident (52.6% versus 39.6%, p=0.006), have stab and/or laceration (9.0% versus 2.0%, p=0.004) or have been assaulted (6.9% versus 2.6%, p=0.047). Injury severity was not significantly different between genders based on the median Kampala Trauma Score and presence of triage hypotension. For treatments females were more likely to have been transported by prehospital services (87.7% versus 72.9%, p=0.001), but were less likely to received acute ED treatments of intubation, wound care, tourniquets, blood products, thoracostomy and point-of-care ultrasound during the first six hours of care (67.5% versus. 78.1%, p=0.009). Hospital admission was significantly greater among females as compared to males, (31.2% versus 41.8%, p=0.019) but no difference in mortality was observed (2.0% versus 1.3%, p=0.568).Conclusion:This study provides data on differences in epidemiologic and care characteristics between males and females presenting for emergency injury care in Rwanda. These findings can inform future research and help the development of gender-centered healthcare delivery in Rwanda and other similar contexts.

Benefits of a Mentorship Program on Interprofessional Collaboration in Obstetric and Neonatal Care in Rwanda: A Qualitative Descriptive Case Study

BackgroundInterprofessional collaboration (IPC) contributes to optimum patient outcomes. The Training, Support, Access Model for Maternal, New Born, and Child Health (TSAM – MNCH), a project initiated as an innovative model for Rwanda, has provided a mentorship program to improve the quality of emergency obstetric and neonatal care (EmONC )including IPC. However, no research has been conducted to understand the impact of that mentorship on IPC practice.Study objectiveTo identify the impact of the TSAM mentorship on IPC practice in Rwanda from the perspective of hospital managers where TSAM mentorship was implemented and healthcare professionals (HCPs) participated in the mentoring program.MethodsA qualitative descriptive case study was conducted in five district hospitals in the Northern Province of Rwanda. Interviews were conducted with hospital directors and twenty-five HCPs mentees. Data were recorded, transcribed verbatim, and analyzed to identify emergent themesResults and discussionsFour themes emerged: a) experience with IPC and TSAM mentorship; b) benefits of TSAM mentorship on IPC, c) challenges with mentoring programs, and 4) suggestions to improve TSAM mentorshipConclusionThe findings indicated an increase in self-confidence and awareness of responsibilities, which contributed to the improved working relationship among the team involved in EmONC.Rwanda J Med Health Sci 2023;6(1):71-83

Multidisciplinary approach to cancer care in Rwanda: the role of tumour board meetings

Multidisciplinary approach to cancer care in Rwanda: the role of tumour board meetings

Determinants of timing, adequacy and quality of antenatal care in Rwanda: a cross-sectional study using demographic and health surveys data

BackgroundAntenatal care (ANC) is a recommended intervention to lessen maternal and neonatal mortality. The increased rate in ANC coverage in most Sub-Saharan African countries is not considerably reducing the maternal and neonatal mortality. This disconnection has raised concerns to study further the trend and determinants of the ANC timing and quality. We aimed to assess the determinants and trend of the timing, the adequacy and the quality of antenatal care in Rwanda.MethodA population-based cross-sectional study design. We used data from the 2010,2015 and 2020 Rwanda demographic and health surveys (RDHS). The study included 18,034 women aged 15–49 years. High quality ANC is when a woman had her first ANC visit within 3 months of pregnancy, had 4 or more ANC visits, received services components of ANC during the visits by a skilled provider. Bivariate analysis and multivariable logistic regression were used to assess the ANC (timing and adequacy), the quality of the content of ANC services and the associated factors.ResultsThe uptake of antenatal services increased in the last 15 years. For instance, the uptake of adequate ANC was 2219(36.16%), 2607(44.37%) and 2925(48.58%) respectively for 2010;2015 and 2020 RDHS. The uptake of high quality ANC from 205(3.48%) in 2010 through 510(9.47%) in 2015 to 779(14.99%) in 2020. Women with unwanted pregnancies were less likely to have timely first ANC (aOR:0.76;95%CI:0.68,0.85) compared to planned pregnancies, they were also less likely to achieve a high-quality ANC (aOR: 0.65;95%CI:0.51,0.82) compared to the planned pregnancies. Mothers with a secondary and higher education were 1.5 more likely to achieve a high-quality ANC (aOR:1.50;95%CI:1.15,1.96) compared to uneducated mothers. Increasing maternal age is associated with reduced odds of update of ANC component services (aOR:0.44;95%CI:0.25,0.77) for 40 years and above when referred to teen mothers).ConclusionLow-educated mothers, advanced maternal age, and unintended pregnancies are the vulnerable groups that need to be targeted in order to improve ANC-related indicators. One of the credible measures to close the gap is to strengthen health education, promote family planning, and promote service utilization.

Multidisciplinary approach to cancer care in Rwanda: the role of tumour board meetings.

Cancer treatment is complex and necessitates a multidisciplinary approach. Tumour Board Meetings (TBMs) provide a multidisciplinary platform for health care providers to communicate about treatment plans for patients. TBMs improve patient care, treatment outcomes and, ultimately, patient satisfaction by facilitating information exchange and regular communication among all parties involved in a patient's treatment. This study describes the current status of case conference meetings in Rwanda including their structure, process and outcomes. The study included four hospitals providing cancer care in Rwanda. Data gathered included patients' diagnosis, number of attendance and pre-TBM treatment plan, as well as changes made during TBMs, including diagnostic and management plan changes. From 128 meetings that took place at the time of the study, Rwanda Military Hospital hosted 45 (35%) meetings, King Faisal Hospital had 32 (25%), Butare University Teaching Hospital (CHUB) had 32 (25%) and Kigali University Teaching Hospital (CHUK) had 19 (15%). In all hospitals, General Surgery 69 (29%) was the leading speciality in presenting cases. The top three most presented disease site were head and neck 58 (24%), gastrointestinal 28 (16%) and cervix 28 (12%). Most (85% (202/239)) presented cases sought inputs from TBMs on management plan. On average, two oncologists, two general surgeons, one pathologist and one radiologist attended each meeting. TBMs in Rwanda are increasingly getting recognised by clinicians. To influence the quality of cancer care provided to Rwandans, it is crucial to build on this enthusiasm and enhance TBMs conduct and efficiency.

Impact of COVID-19 on access to cancer care in Rwanda: a retrospective time-series study using electronic medical records data

IntroductionThe COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study,...

Integrating Breast Cancer Early Detection Into a Resource-Constrained Primary Health Care System: Health Care Workers' Experiences in Rwanda.

There is limited evidence to guide incorporation of breast cancer early detection into resource-constrained health systems where mammography screening is not yet available. To inform such strategies, we sought to understand health care workers' perspectives on a breast cancer early detection initiative integrated into community, primary, and secondary levels of care in Rwanda. We conducted a qualitative study using semistructured interviews with 33 community health workers, clinicians, and administrators at health facilities participating in the Women's Cancer Early Detection Program (WCEDP), through which women received clinical breast examination if they were receiving cervical cancer screening, or had breast concerns. Through thematic analysis, we identified dynamics and patterns associated with successes and challenges of the program's breast health services. Successes and challenges identified by participants corresponded with the community- and primary care-based steps of cancer early diagnosis identified by the WHO. Regarding step 1 (community awareness/access), participants noted increases in awareness and care-seeking. Challenges included difficulty overcoming stigma and engaging older women. Regarding step 2 (clinical evaluation), all participants described increased breast health knowledge, skills, and confidence. Integrating the WCEDP with other services was challenging because of inadequate staffing; offering WCEDP services on a designated day/week had advantages and disadvantages. Although participants appreciated WCEDP referral mechanisms, they desired more communication from referral facilities. Patients' poverty was the most consistently identified impediment to referral completion. Rwandan health care workers identified real-world successes and challenges of implementing principles of early cancer diagnosis for breast cancer early detection. Future interventions should focus on engagement of older women, community awareness, patient socioeconomic support, and optimizing integration into primary care.