Patient empowerment remains a critical component in the management of non-communicable diseases, particularly in low-resource settings where health system constraints limit continuity of care. Diabetes and hypertension are increasingly prevalent in Rwanda, requiring sustained patient engagement and self-management. This study assessed patient empowerment and explored digital health readiness among individuals receiving care for diabetes and/or hypertension across selected hospitals in Rwanda. A cross-sectional design was employed, involving 930 patients from six hospitals using a structured assessment tool. Patient empowerment was evaluated across domains of knowledge, self-monitoring, treatment adherence, access to care, and support systems, while digital readiness included device ownership and communication preferences. The findings revealed substantial variability in empowerment across facilities, with higher levels in knowledge and confidence compared to access to care, structured education, and support systems. Basic mobile phone ownership was high, while smartphone use and digital literacy remained limited. Patients preferred in-person and printed education as they are used to, although SMS-based communication emerged as the most feasible digital intervention. Overall, patient empowerment remains suboptimal, but SMS-based approaches offer a scalable opportunity to strengthen self-management in resource-limited settings.

Background: Every day we are faced with different treatment claims, in the news, in social media, and by our family and friends. Some of these claims are true, but many are unsubstantiated. Without being supported by reliable evidence such guidance can lead to waste and harmful health choices. The Informed Health Choices (IHC) Network facilitates development of interventions for teaching children and adults the ability to assess treatment claims (informedhealthchoices.org). Our objective was to develop and evaluate a new assessment tool developed from the item bank for use in an upcoming trial of lower secondary school resources in Uganda, Kenya, and Rwanda. Methods: A cross-sectional study evaluating a questionnaire including two item-sets was used. The first evaluated ability using multiple-choice questions (scored dichotomously) and the other evaluated intended behaviour and self-efficacy (measured using Likert scales). This study was conducted in Uganda, Kenya, and Rwanda in 2021. We recruited children (over 12 years old) and adults through schools and our networks. We entered 1,671 responses into our analysis. Summary and individual fit to the Rasch model (including Cronbach’s Alpha) were assessed using the RUMM2030 software. Results: Both item-sets were found to have good fit to the Rasch model and were acceptable to our target audience. The reliability was good (Cronbach’s alpha >0.7). Observations of the individual item and person fit provided us with guidance on how we could improve the design, scoring, and administration of the two item-sets. There was no local dependency in either of the item-sets, and both item-sets were found to have acceptable unidimensionality. Conclusion: To our knowledge, this is the first instrument validated for measuring ability to assess treatment claims in Uganda, Kenya and Rwanda. Overall, the two item-sets were found to have satisfactory measurement properties.

Background:Tuberculosis (TB) remains a major global health challenge, disproportionately affecting vulnerable populations in resource-limited settings. In Rwanda, the burden is high among high-risk groups including prisoners, mining workers, people living with HIV, and healthcare workers. Despite well-established national surveillance infrastructure, published evidence on applying machine learning (ML) to routinely collected electronic medical records (EMR) for identifying factors associated with TB in these populations remains limited. This study develops and compares multiple ML models to identify factors associated with TB among high-risk groups using national surveillance data from Kigali health facilities, while emphasizing careful feature engineering to avoid information leakage. Methods:We conducted a retrospective, cross-sectional analysis of 2,254 high-risk patient EMR from Rwanda Biomedical Center (RBC) surveillance systems, with TB status defined by GeneXpert results. Rigorous data cleaning and preprocessing were performed, including exclusion of records with indeterminate outcomes, removal of diagnostic and operational variables that could introduce information leakage, imputation of missing values, normalization of numerical features, and one-hot encoding of categorical variables. Multiple supervised ML models were developed and evaluated using a stratified train-test split, including logistic regression (LR), balanced random forest (BRF), gradient boosting methods (XGBoost, LightGBM, and GBM), support vector machines (SVM) with a radial basis function kernel, and an EasyEnsemble classifier. Model performance was assessed using accuracy, precision, recall, F1-score, and area under the receiver operating characteristic (ROC) curve (AUC). Results:After excluding indeterminate GeneXpert outcomes, 358 cases were retained for evaluation. Ensemble-based models showed consistently strong and stable performance, with BRF achieving the highest discrimination (AUC = 0.86), while GBM, SVM, and EasyEnsemble classifiers showed comparable performance across accuracy, precision, recall, and F1-score. Feature-importance analysis identified clinically meaningful factors, associated with TB, including site of disease, age, TB-related body mass index, HIV status, and diabetes status, indicating that the models relied on plausible biological and demographic risk factors rather than diagnostic artifacts. Conclusions:This first application of EMR-driven ML for identifying TB risk factor associations in Rwanda shows that ensemble models, combined with rigorous leakage control, achieve promising performance among high-risk populations. These tools could support national TB surveillance and screening to enhance early detection and resource allocation.

Background People need critical thinking skills to make well-informed health choices and avoid waste and unnecessary suffering. However, educational interventions can have adverse effects, which is often overlooked. We created a framework of potential harms of interventions to improve critical thinking about health choices. The objective was to identify potential effects and articulate potential mechanisms. We intended to use the framework to inform the development and evaluation of an intervention in Kenya, Rwanda, and Uganda. Methods We created an initial framework drawing on two earlier frameworks. We surveyed external experts using Likert-scale and open-ended items, including researchers, educators, and others, in a variety of relevant fields. We emailed the survey to an international advisory network, and all other experts recommended by respondents. We analyzed the quantitative data using descriptive statistics. We conducted a thematic analysis of the qualitative data. We revised the framework based on those results. To identify any effects missing from the revised framework, we individually interviewed a convenience sample of one teacher from each of Kenya, Rwanda, and Uganda. Results We received responses from 38 of 70 external experts (54%). The quantitative survey data suggested respondents agreed with the initial framework overall. However, the qualitative data led to substantial revisions. The revised framework consists of categories of adverse outcomes; outcomes within each category; sub-outcomes; individuals, groups, and populations that might experience each adverse outcome; beneficial outcomes corresponding with adverse outcomes; and potential mechanisms of adverse effects. There are six categories: decision-making harms, psychological harms, equity harms, group and social harms, waste, and other harms. In the interviews with teachers, we did not identify any effects missing from the revised framework. Conclusions As far as we know, the framework is the first tool of its kind for education research. It can be improved upon and adapted.

OBJECTIVES:To explore participants' experiences of potential adverse effects of the Informed Health Choices secondary school intervention across three trial sites and to revise a framework of potential adverse effects of interventions to improve critical thinking about health choices. DESIGN:This was a qualitative study. We extracted and analysed relevant data from separate process evaluations in each country. Data came from surveying teachers, observing lessons and group and individual interviews with students, teachers and other stakeholders. We modified and applied framework analysis, including five stages: (1) development of an initial framework of potential adverse effects, (2) familiarisation with the data, (3) indexing, (4) abstraction and synthesis and (5) revising the framework. We applied reflexive strategies individually and as a team. SETTING:Lower secondary school in five randomly sampled subcounties of Kisumu County in Kenya, districts representing all five provinces in Rwanda, and six districts in the central region of Uganda, between 2022 and 2024. PARTICIPANTS:Students and teachers in the intervention arms of the trials, parents of students in the intervention arms and administrators at intervention schools, as well as curriculum developers and policy-makers. INTERVENTION:The intervention involved providing teachers with a 2-3-day training workshop, and digital classroom resources, including lesson plans for 10 lessons to be delivered over the course of one semester. RESULTS:We generated findings about potential increases in adverse misunderstandings, anxiety related to transfer of learning, adversely experienced cognitive dissonance, work or schoolwork-related stress, inequity, conflicts and waste. The revised framework includes the same categories of potential adverse effects as our initial framework: decision-making harms, psychological harms, equity harms, group and social harms, waste and other harms. We revised other elements of the framework, including definitions of the categories and its structure. CONCLUSIONS:This study provides insight into the potential adverse effects of interventions to improve critical thinking about health choices. The findings complement those of the trials and country-level process evaluations.

Data quality remains a critical issue in the adoption and use of electronic medical records (EMR) systems, particularly in low-resource settings. The mUzima-OpenMRS application was introduced in Rwanda to support community-based screening and management of non-communicable diseases, particularly hypertension and diabetes. This study assessed the completeness and uniqueness of data recorded in the mUzima application by community health workers (CHWs) in three districts. We used a cross-sectional study design and extracted 231,799 patient records entered between April 1, 2023, and March 31, 2024. Data completeness was measured as the proportion of fully recorded variables, while uniqueness was assessed as the proportion of patients uniquely identified. We found that 88.8% of all records were uniquely identified, and all variables were completed at a rate of 81.1%. These findings suggest that data quality in the mUzima application is high in terms of uniqueness and completeness. However, strengthening data quality controls within the application could further improve completeness and uniqueness of patient data.

The aim of this study was to evaluate the effects of the Informed Health Choices secondary school intervention on the ability of students in Rwanda to think critically and make informed health choices after 1 year. This was a two-arm cluster-randomized trial conducted in 84 lower secondary schools from 10 districts representing five provinces of Rwanda. We used stratified randomization to allocate schools 1:1 to the intervention or control arm. One class in each intervention school had ten 40-min lessons taught by a trained teacher in addition to the usual curriculum. Control schools followed the usual curriculum. The primary outcome was a passing score (≥ 9 out of 18 questions answered correctly) for students on the Critical Thinking about Health Test completed 1 year after the intervention. We conducted an intention to treat analysis using generalized linear mixed models, accounting for the cluster design using random intercepts. After 1 year, 35 of 42 teachers (83.3

The aim of this study was to evaluate the effects of the Informed Health Choices secondary school intervention on the ability of students in Rwanda to think critically and make informed health choices after 1 year. This was a two-arm cluster-randomized trial conducted in 84 lower secondary schools from 10 districts representing five provinces of Rwanda. We used stratified randomization to allocate schools 1:1 to the intervention or control arm. One class in each intervention school had ten 40-min lessons taught by a trained teacher in addition to the usual curriculum. Control schools followed the usual curriculum. The primary outcome was a passing score (≥ 9 out of 18 questions answered correctly) for students on the Critical Thinking about Health Test completed 1 year after the intervention. We conducted an intention to treat analysis using generalized linear mixed models, accounting for the cluster design using random intercepts. After 1 year, 35 of 42 teachers (83.3%) and 1181 of 1556 students (75.9%) in the control arm completed the test. In the intervention arm, 35 of 42 teachers (83.3%) and 1238 of 1572 students (78.8%) completed the test. The proportion of students who had a passing score in the intervention arm was 625/1238 (50.5%) compared to 230/1181 (19.5%) in the control arm (adjusted odds ratio 7.6 [95% CI: 4.6–12.6], p < 0.0001). The adjusted difference in the proportion of students with a passing score was 32.2% (95% CI 24.5–39.8%). The IHC secondary school intervention was effective after 1 year. However, the size of the effect was smaller than immediately after the intervention (adjusted difference 32.2% vs 37.2%) due to decay in the proportion of students in intervention schools with a passing score (50.5% vs 58.2%). Pan African Clinical Trial Registry (PCTR), trial identifier: PACTR202203880375077. Registered on February 15, 2022.

Vaccine misinformation causes negative impacts such as decreased vaccine acceptance and reduced intent to get vaccinated. The association between susceptibility to vaccine misinformation and vaccine hesitancy underscores the need for interventions that increase public resilience against misinformation. One promising intervention is psychological inoculation, where recipients receive a “weakened form” of misinformation to build immunity to real-world misinformation. Misinformation is delivered in weakened form by exposing its misleading techniques. Cranky Uncle Vaccine is an interactive, digital game that applies inoculation theory, explaining facts about vaccines as well as the misleading techniques used to cast doubt on the facts. We document a pilot study testing the effectiveness of an East African version of Cranky Uncle Vaccine conducted in Rwanda. Two translations of the game were made available with participants choosing either a Kinyarwandan-speaking (n = 535) or French-speaking (n = 499) version. Among Kinyarwandan-speaking players, the average age was 27.8 years with more males (52.7%) than females (46.9%). Among French-speaking players, the average age was 29.9 years with more males (55.3%) than females (44.7%). Among both languages, participants were highly educated (median education level “Some/all university”). Before and after playing the game, participants filled out surveys measuring vaccine attitudes and discernment between facts and fallacies. French-speaking participants showed significant improvement in general vaccine attitude and vaccine importance but while the change in intent to get vaccinated was positive, it was not statistically significant. Kinyarwandan-speaking players showed significant improvement in general vaccine attitude, vaccine importance, and intent to get vaccinated. The game was most effective among players who expressed vaccine hesitancy in the pre-game survey with 55% of hesitant French-speaking participants and 71% of Kinyarwandan-speaking participants switching to being likely to get vaccinated. These results show that a digital game employing an inoculation approach is effective in building public resilience against vaccine misinformation and boosting vaccine acceptance, particularly among those expressing vaccine hesitancy.

The management of NCDs require a secure and continuous collection and use of patient data to improve care and treatment. The OpenMRS NCDs module was developed and piloted in three districts to ascertain the possibility of using it in early detection and management of Hypertension and Diabetes in Rwanda. This paper explored the user experience NCDs module of OpenMRS, an open sources EMR used in health centers of Rwanda. We used two methods to explore the user experience of the system among the nurses: Key informant interviews and observations. We analysed the data using thematic content analysis and drawn upon the views and expectations of the users to experience effective use of the system. We collected the data using the developed and piloted tools. In this study we interviewed 10 nurses and observed how they complete tasks in the system. In general, the nurses found that the system was useful because it simplified patient care and reporting. Some barriers related to the use of the system were slowness of the system, and turnover of trained users. We concluded that during the first 12 months of the pilot of the OpenMRS in 5 hospitals located in three districts, nurses were able to use the system with limited and manageable challenges. However, some challenges related to system design and navigations should be addressed before wider implementation.

Background Learning to thinking critically about health information and choices can protect people from unnecessary suffering, harm, and resource waste. Earlier work revealed that children can learn these skills, but printing costs and curricula compatibility remain important barriers to school implementation. We aimed to develop a set of digital learning resources for students to think critically about health that were suitable for use in Kenyan, Rwandan, and Ugandan secondary schools. Methods We conducted work in two phases collaborating with teachers, students, schools, and national curriculum development offices using a human-centred design approach. First, we conducted context analyses and an overview of teaching strategies, prioritised content and collected examples. Next, we developed lessons and guidance iteratively, informed by data from user-testing, individual and group interviews, and school pilots. Results Final resources include online lesson plans, teachers’ guide, and extra resources, with lesson plans in two modes, for use in a classroom equipped with a blackboard/flip-chart and a projector. The resources are accessible offline for use when electricity or Internet is lacking. Teachers preferred the projector mode, as it provided structure and a focal point for class attention. Feedback was largely positive, with teachers and students appreciating the learning and experiencing it as relevant. Four main challenges included time to teach lessons; incorrect comprehension; identifying suitable examples; and technical, logistical, and behavioural challenges with a student-computer mode that we piloted. We resolved challenges by simplifying and combining lessons; increasing opportunities for review and assessment; developing teacher training materials, creating a searchable set of examples; and deactivating the student-computer mode. Conclusion Using a human-centred design approach, we created digital resources for teaching secondary school students to think critically about health actions and for training teachers. Be smart about your health resources are open access and can be translated or adapted to other settings.

Mobile technology has become the leading utility in the social and well-being of people especially in low-resource settings. The use of mobile applications in healthcare promise to improve care and treatment. This study explored the user experience of muzima mobile application among community health workers in Rwanda. We used three data collection methods: observation, Key informant interviews and focus group discussions. We analysed data using thematic content analysis. We found that users were able to complete tasks in the app although some less experienced and older participants struggled to complete the tasks. Users felt that the application helped them to screen and manage patients with diabetes and hypertension in the community which reduced frequent visits to the health centers. Users felt that the application needs improvements in the workflow to facilitate the ease of use. They suggested to digitse other health programs implemented by community health workers. To improve the use and ensure wider implementation, there is a need to consider users' needs and concerns as discussed in this paper.

Background 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. Objective 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. Methods 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. Results 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). Conclusions 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.

Background Learning to thinking critically about health information and choices can protect people from unnecessary suffering, harm, and resource waste. Earlier work revealed that children can learn these skills, but printing costs and curricula compatibility remain important barriers to school implementation. We aimed to develop a set of digital learning resources for students to think critically about health that were suitable for use in Kenyan, Rwandan, and Ugandan secondary schools. Methods We conducted work in two phases collaborating with teachers, students, schools, and national curriculum development offices using a human-centred design approach. First, we conducted context analyses and an overview of teaching strategies, prioritised content and collected examples. Next, we developed lessons and guidance iteratively, informed by data from user-testing, individual and group interviews, and school pilots. Results Final resources include online lesson plans, teachers’ guide, and extra resources, with lesson plans in two modes, for use in a classroom equipped with a blackboard/flip-chart and a projector. The resources are accessible offline for use when electricity or Internet is lacking. Teachers preferred the projector mode, as it provided structure and a focal point for class attention. Feedback was largely positive, with teachers and students appreciating the learning and experiencing it as relevant. Four main challenges included time to teach lessons; incorrect comprehension; identifying suitable examples; and technical, logistical, and behavioural challenges with a student-computer mode that we piloted. We resolved challenges by simplifying and combining lessons; increasing opportunities for review and assessment; developing teacher training materials, creating a searchable set of examples; and deactivating the student-computer mode. Conclusion Using a human-centred design approach, we created digital resources for teaching secondary school students to think critically about health actions and for training teachers. Be smart about your health resources are open access and can be translated or adapted to other settings.

Introduction: Accurate and timely nutritional information plays a vital role in monitoring the progress of the Rwandan National Nutrition Program (NNP). However, the absence of a cohesive reporting system to monitor child growth and nutrition poses a challenge. This study focuses on analyzing health workers' utilization of health information management systems (HMIS) to identify areas for enhancement in program implementation. Methods: Our interview guide and group discussion questions were structured around the constructs of the Human, Organization, and Technology–Fit (HOT-Fit) framework. These guided discussions were conducted with health workers supporting the NNP children in primary health facilities across three districts in Rwanda. The subsequent data analysis involved importing the transcripts into NVivo for interpretation within the framework. Results: Health care providers, including community health workers and nutritionists, rely on paper registers for tracking and reporting nutritional data. Data managers store this information digitally, preferring HMIS for increased efficiency. They find use of digital entry and reporting faster and less cumbersome compared to paper-based systems. Respondents identified challenges with paper-based registration, noting repetitive entries and inconsistencies across registers. Nutrition information within HMIS faces obstacles such as a lack of nutritionists, suboptimal system use, limited internet access, and low digital literacy among staff. Conclusion: Addressing challenges such as documentation practices and staffing is crucial for enhancing user satisfaction. The integration of routine recording systems can significantly improve data utilization. This study underscores the importance of tailored digital health interventions to enhance the HMIS supporting the National NNP.

INTRODUCTION:We evaluated the Informed Health Choices secondary school intervention to help students in Kenya think critically about health choices. We conducted this process evaluation to explore if the intervention was implemented as planned, identify factors that facilitated or hindered implementation, potential benefits of the intervention, and how to scale up the intervention beyond the trial. METHODS:This was a mixed methods process evaluation nested in a cluster-randomized trial of the Informed Health Choices intervention. We analyzed quantitative data from teacher training evaluation forms completed by 39 teachers, 10 lesson evaluation forms completed by 40 teachers allocated to the intervention, and 72 structured classroom observation forms. We conducted a framework analysis of qualitative data from 14 group interviews (with 96 students, 23 teachers, and 18 parents) and 22 individual interviews (with 8 teachers, 5 school principals, 6 curriculum developers, and 3 policymakers). We assessed confidence in our findings from the qualitative analysis using a modified version of Confidence in the Evidence from Reviews of Qualitative Research. RESULTS:Lesson objectives were achieved with minimal adaptations. Factors that might have facilitated the implementation of the intervention include teacher training; perceived value of the intervention by students, teachers, and policymakers; and support from school administration. Time constraints, teachers' heavy workloads, and the lessons not being included in the curriculum or national examination are factors that might have impeded implementation. Both students and teachers demonstrated the ability to apply key concepts that were taught to health choices and other choices. However, they experienced difficulties with 2 of the lessons. CONCLUSION:Scale-up of this intervention in Kenyan schools is feasible but may depend on adjusting the time allocated to teaching the lessons, modifying the 2 lessons that teachers and students found difficult, and including the lesson objectives and assessment in the national curriculum.

Purpose: CyberRwanda is a digital health intervention designed to increase knowledge of family planning and reproductive health (FP/RH) and access to youth -friendly services in Rwanda. Methods: Sixty schools in eight districts were randomized 1:1:1 to one of two CyberRwanda implementation models -self-service (tablet -only) or facilitated (tablet, activity booklet, peer facilitators) -or to control. Students aged 12-19 years were randomly selected to participate. Baseline and 12 -month midline surveys assessed intermediate (secondary) outcomes of FP/RH and HIV knowledge, attitudes/beliefs, self -ef ficacy, and behavior. Prevalence differences (PDs) were estimated using generalized linear mixed models. Results: There were 5,767 midline participants (51% female, mean/median age: 16 years, 29.9% sexually active). Those in CyberRwanda schools had higher knowledge of emergency contraception (57.3% vs. 47.5%, PD: 0.09, 95% con fidence interval [CI]: 0.05-0.13); greater con fidence in providing consent (73.3% vs. 68.1%, PD: 0.05, 95% CI: 0.01-0.08), negotiating partner 's contraceptive use (88.3% vs. 85.0%, PD: 0.03, 95% CI: 0.01-0.06), and accessing/using contraceptive services (95.6% vs. 91.8%, PD: 0.03, 95% CI: 0.02-0.05); and more favorable views on FP/RH services (54.5% vs. 48.5%, PD: 0.06, 95% CI: 0.02-0.11) and condoms (76.9% vs. 71.3%, PD: 0.06, 95% CI: 0.03-0.08) compared to control. No signi ficant differences in HIV/fertility knowledge, con fidence in accessing HIV testing, or condom use were observed. Discussion: CyberRwanda increased FP/RH knowledge, supportive attitudes/beliefs, self -ef ficacy, and behavior at 12 months. The 24 -month endline analysis will reveal whether CyberRwanda 's bene fits on intermediate outcomes result in changes to the primary outcomes, including contraception use and childbearing. (c) 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY -NC -ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

We conducted a cluster-randomized hybrid effectiveness-implementation study of CyberRwanda, a digital family planning and reproductive health intervention for Rwandan adolescents. Sixty schools were randomized 1:1:1 to control or to one of two implementation models-self-service (self-guided access on tablets) or facilitated (peer-led clubs plus tablet access) with no masking. Eligible participants were aged 12-19 years, in secondary school levels 1 or 2, and willing to provide consent or assent/parental consent and contact information for follow-up. In 2021, 6,078 randomly selected adolescents were enrolled. At 24 months, 91.3% of participants were retained and included in the primary intention-to-treat analyses (control, n = 1,845; self-service, n = 1,849 and facilitated, n = 1,858). There were no adverse events related to the study. CyberRwanda did not affect the primary outcomes of modern contraceptive use (prevalence ratio (PR) = 1.04; 95% confidence interval (CI) = 0.76, 1.42), childbearing (PR = 1.33; 95% CI = 0.71, 2.50) and HIV testing (PR = 1.00; 95% CI = 0.91, 1.11) in the full sample. Significantly higher modern contraceptive use observed in the CyberRwanda facilitated arm in a prespecified analysis of sexually active participants suggests that longer-term evaluation is needed to examine effects as more of the study population becomes sexually active and has increased demand for contraception. ClinicalTrials.gov registration: NCT04198272. An implementation trial conducted across 60 schools in Rwanda found that CyberRwanda, a digital, school-based intervention, did not affect the primary outcomes of modern contraceptive use, childbearing and HIV testing among adolescents but was associated with higher contraceptive use among sexually active participants.

Abstract Background Critical thinking about health choices is essential to avoid being misled by unreliable information and to use reliable information appropriately. The aim of this prospective meta-analysis was to synthesize the results of 1-year follow-up data from three cluster-randomized trials of an intervention designed to teach lower secondary school students to think critically about health choices. Only one other randomized trial has evaluated a school-based intervention to teach adolescents to think critically about health choices. That trial compared two teaching strategies to teach statistical reasoning. It did not assess long-term learning-retention. Methods We conducted the trials in Kenya, Rwanda, and Uganda. The intervention included providing a 2–3-day teacher training workshop and digital resources for ten lessons. The intervention focused on nine key concepts. We did not intervene in control schools. The primary outcome was a passing score on a test (≥ 9 of 18 multiple-choice questions answered correctly). We performed random effects meta-analyses to estimate the overall intervention effects. We calculated learning retention as the test results in the intervention schools after 1 year relative to just after the intervention, adjusted for chance. Results Altogether, 244 schools (11,344 students) took part in the three trials. Follow-up data was collected for 8298 students (73%). The overall odds ratio for the primary outcome after 1 year was 3.6 (95% CI: 1.9–7.1; p = 0.0001) in favor of the intervention, whereas it was 5.5 (95% CI: 3.0–10.2) just after the intervention. This corresponds to 25.6% (95% CI: 21.1–30.0%) more students in the intervention schools passing the test after 1 year versus 33.3% (95% CI: 28.7–37.8%) just after the intervention. Overall, 2273 (52.6%) of 4324 students in intervention schools had a passing score after 1 year compared to 3397 (58.1%) of 5846 students just after the intervention, indicating 88.3% learning retention. Conclusions One year after the intervention, we still found a positive effect on the ability of students to think critically about health choices, but 5.5% fewer students in the intervention schools had a passing score. The certainty of the evidence was also lower due to 27% of students being lost to follow-up. Trial registration The protocol for this prospective meta-analysis was registered with PROSPERO May 31, 2022, ID 336580. The three randomized trials were registered in the Pan African Clinical Trial Registry February 15, 2022, PACTR202203880375077; April 5, 2022, PACTR20220488391731; and April 14, 2022, PACTR202204861458660.