A Decade Later, How Much of Rwanda's Musculoskeletal Impairment Is Caused by the War in 1994 and by Related Violence? (original) (raw)
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World Journal of Surgery, 2011
Background The present study examines demographics, causes, and diagnoses of traumatic musculoskeletal impairment (MSI) in Rwanda and identifies treatment barriers in order to describe the injury burden and inform service planning. Methods In all, 105 clusters were chosen by multistage stratified cluster random sampling with probability proportional to size. Eighty people from each cluster were identified for screening by a modified compact segment sampling method. A screening questionnaire was applied and suspected cases and 10% of suspected non-cases underwent standardized examination. A structured interview obtained a detailed history, and an algorithmic classification system allocated diagnosis. Results Of 8,368 enumerated subjects, 6,756 were screened. Of these, 111 were traumatic MSI cases, with 121 diagnoses, giving a prevalence of 1.64% (95% CI 1.35-1.98). Extrapolation to the Rwandan population estimates 68,716 traumatic MSI cases, mostly in people of working age. Most affected were hand/finger joints (23%), elbow (16%), shoulder region (9%), and knee joint (9%). Some 11% of impairments were severe, 47.7% were moderate, and 41.3% were mild. Most common diagnoses were fracture malunion (21.5%) and post-traumatic joint stiffness (20.7%). The number of treatments needed was 199, including physiotherapy (87.2%) and surgery (53.7%), but 43% (95% CI 34-53) received less treatment than required. Of those who were undertreated, 63% cited cost. Conclusions In Rwanda the prevalence of traumatic MSI of 1.64%, mostly in people of working age, makes usual activities difficult or impossible and is therefore a significant national burden. The results of the present study identify the need for immediate surgical intervention and physiotherapy, with cost as a treatment barrier. This study may direct aid providers toward subsidizing access to orthopedic care and thus reduce the impact of traumatic MSI.
Mental and physical health in Rwanda 14 years after the genocide
Social Psychiatry and Psychiatric Epidemiology, 2012
Purpose To examine the socio-demographic determinants of post-traumatic stress disorder (PTSD) and its association with major depressive episode and self-perceived physical and mental health in a large random sample of the Rwandan population 14 years after the 1994 genocide. Methods Using the Mini International Neuropsychiatric Interview and Medical Outcomes Study 36-Item Short-Form (SF-36) translated in Kinyarwanda, we interviewed 1,000 adult residents from the five provinces of Rwanda. Sociodemographic data and specific somatic symptoms were also recorded. Data analysis included 962 questionnaires. Results Participants were predominantly female (58.9%), aged between 16 and 34 years (53.2%), with a low level of education (79.7% below secondary school). Prevalence of PTSD was estimated to be 26.1%. In multivariable analysis, factors associated with PTSD were being aged between 25 and 34 years, living in extreme poverty, having endured the murder of a close relative in 1994, being widowed or remarried, having lost both parents and living in the South Province. Participants who fulfilled diagnostic criteria for PTSD were significantly more often affected with major depression (68.4 vs. 6.6%, P \ 0.001) and substance dependence (7.6 vs. 3.5%, P = 0.013) than respondents without PTSD. They scored significantly lower on all SF-36 subscales. Somatic symptoms such as hiccups, fainting and loss of speech or hearing delineated a specific pattern of post-traumatic stress syndrome. Conclusions PTSD remains a significant public health problem in Rwanda 14 years after the genocide. Facilitating access to appropriate care for all those who need it should be a national priority.
Trauma and PTSD Symptoms in Rwanda
JAMA, 2004
The 1994 genocide in Rwanda led to the loss of at least 10% of the country's 7.7 million inhabitants, the destruction of much of the country's infrastructure, and the displacement of nearly 4 million people. In seeking to rebuild societies such as Rwanda, it is important to understand how traumatic experience may shape the ability of individuals and groups to respond to judicial and other reconciliation initiatives.
Psychological Trauma: Theory, Research, Practice, and Policy, 2014
This study examines levels of traumatic stress reactions among youth attending school in the second year after the 1994 Rwandan genocide. From August to December 1995, the survey team visited 22 schools throughout Rwanda. The survey (n ϭ 942; youth aged 8 to 19 years) assessed exposure to wartime violence and symptoms of posttraumatic stress disorder (PTSD), as outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV; American Psychiatric Association, 2000). Mean symptom levels and the proportion of respondents meeting DSM-IV PTSD symptom criteria ("probable PTSD") were examined for evidence of systematic decline over time. Multivariate analyses controlled for major confounders and the complex survey design. Overall, traumatic stress reactions increased among youth interviewed at successively later time points. For example, in the first third of the survey period, the "probable PTSD" rate was 48%; in the second, 54%; and in the third, 58%. The rise was confined to females. Among females, the adjusted odds of having "probable PTSD" in the last third of the study period was 2.71 (95% CI [1.66, 4.43]) fold higher than in the first. These results suggest that in planning health services in postconflict settings, humanitarian agencies should be alert to the possibility that traumatic stress reactions among youth may not decline with passage of time. Despite limitations in design, to date, this report represents the only formal structured evaluation of the mental health of youth living in the community, in the very early aftermath of catastrophic violence.
Journal of Traumatic Stress
Historical trauma is a relatively new concept in the literature, and investigations are needed to clarify its clinical aspects and develop instruments to measure its sequelae. The purpose of this study was to develop the Clinical Aspects of Historical Trauma Questionnaire (CAHTQ), which is meant to capture trauma sequelae in different contexts, and provide initial psychometric information. Participants were survivors of the genocide against the Tutsi in Rwanda (N = 261) aged 32–87 years (M = 46.30 years, SD = 11.95) who completed a preliminary version of the CAHTQ, constructed based on theoretical and content‐related consideration, as well as the International Trauma Questionnaire, Fatalism Scale, Public Health Depression Questionnaire, Brief Coping Inventory, Forgiveness Questionnaire, and Sentiment of Reconciliation Questionnaire to test the discriminant and convergent validity of the CAHTQ. Exploratory factor analysis was conducted to reduce the number of items and extract factor...
Trauma care and referral patterns in Rwanda: implications for trauma system development
Canadian Journal of Surgery, 2016
Background: Trauma remains a leading cause of death worldwide. The development of trauma systems in low-resource settings may be of benefit. The objective of this study was to describe operative procedures performed for trauma at a tertiary care facility in Kigali, Rwanda, and to evaluate geographical variations and referral patterns of trauma care. Methods: We retrospectively reviewed all prospectively collected operative cases performed at the largest referral hospital in Rwanda, the Centre Hospitalier Universitaire de Kigali (CHUK), between June 1 and Dec. 1, 2011, for injury-related diagnoses. We used the Pearson χ 2 and Fisher exact tests to compare cases arising from within Kigali to those transferred from other provinces. Geospatial analyses were also performed to further elucidate transfer patterns. Results: Over the 6-month study period, 2758 surgical interventions were performed at the CHUK. Of these, 653 (23.7%) were for trauma. Most patients resided outside of Kigali city, with 337 (58.0%) patients transferred from other provinces and 244 (42.0%) from within Kigali. Most trauma procedures were orthopedic (489 [84.2%]), although general surgery procedures represented a higher proportion of trauma surgeries in patients from other provinces than in patients from within Kigali (28 of 337 [8.3%] v. 10 of 244 [4.1%]). Conclusion: To our knowledge, this is the first study to highlight geographical variations in access to trauma care in a low-income country and the first description of trauma procedures at a referral centre in Rwanda. Future efforts should focus on maturing prehospital and interfacility transport systems, strengthening district hospitals and further supporting referral institutions. Contexte : Les traumatismes demeurent l'une des principales causes de décès dans le monde. La mise au point de systèmes de traumatologie dans des milieux défavorisés pourrait toutefois contribuer à améliorer la situation. Notre étude avait pour objectif de décrire les interventions chirurgicales pratiquées sur les victimes de traumatismes dans un établissement de soins tertiaires de Kigali, au Rwanda, et d'évaluer les variations géographiques et les habitudes d'orientation des patients dans le domaine de la traumatologie. Méthodes : Nous avons évalué rétroactivement les données recueillies de façon prospective sur l'ensemble des interventions réalisées au plus grand centre hospitalier régional du Rwanda, le Centre hospitalier universitaire de Kigali (CHUK), du 1 er juin au 1 er décembre 2011 pour les diagnostics liés à des blessures. Nous avons eu recours au test χ² de Pearson et au test exact de Fisher pour comparer les cas issus de la province de Kigali à ceux provenant d'autres provinces. Nous avons en outre effectué des analyses géospatiales afin de mieux comprendre les habitudes d'orientation des patients. Résultats : Au cours des 6 mois de l'étude, 2758 interventions chirurgicales ont été pratiquées au CHUK, dont 653 (23,7 %) pour des traumatismes. La majorité des patients résidaient à l'extérieur de la capitale : 337 (58,0 %) d'entre eux avaient été transférés d'autres provinces, et 244 (42,0 %), d'ailleurs dans la province. Si la plupart des interventions chirurgicales étaient orthopédiques (489, soit 84,2 %), les patients d'autres provinces ont plus souvent subi des interventions générales que leurs compatriotes de la province de Kigali (28 sur 337, soit 8,3 %, par rapport à 10 sur 244, soit 4,1 %).