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Introducing and testing the WHO CEQ framework in Rwanda

A technical meeting was held in May 2018 in Kigali to introduce the CEQ framework, assess its utility and create an action plan for next steps. The meeting was hosted by National Malaria Control Program (NMCP), known in Rwanda as the Malaria & Other Parasitic Diseases Division (MOPDD) of the Rwanda Biomedical Center (RBC). During the three-day meeting, in addition to key information regarding malaria across the country, the development of the CEQ was presented along with an overview and discussion of the data collection and analysis process. By the conclusion of the meeting a team, headed by the Division Manager – Malaria, with key stakeholders and supported by the WHO Country Office, was created. This group met to discuss the process and procedures necessary to conduct a pilot assessment in four districts using the CEQ framework. It was agreed to proceed in two phases. The first phase to test the CEQ assessment tools and the second phase to use the data from the first phase to develop a set of CE interventions.

A detailed proposal to field-test the CEQ assessment tools was developed over several months through a collaborative process leading to an October 2018 timeframe being set to conduct the data collection for the assessment. The CEQ data collection process was built on the same collaborative assumptions as the CE process was designed to assess. Consequently, the principle researcher worked with the MOPDD, WHO country office, and NGO personnel to develop the inquiry guide for the study. This process produced the inquiry guide that would be used for the collection of data in the four districts selected. Once the questions for the inquiry guide were developed the next step in collaboration took place.

The MOPDD had selected 12 people to serve as data collectors. These people were brought together for two days to be trained and to establish the plan of action for the data collection. During this time the data collectors were provided an overview of the CEQ along with a discussion of how their role is situated in the process. They were then provided the questions that comprised the inquiry guide. At this point the data collectors divided into two groups. Each group took the questions and proceeded to translate them from English into Kinyarwanda. This served multiple functions, including:

•    Facilitating interview response by collecting data in the local language
•    Familiarizing the data collectors with the questions in the inquiry guide. By working with the questions and discussing the proper translation important discussion ensued regarding what the question was meant to achieve and how to best convey that meaning in the interviews
•    Creating an opportunity for additional within context input regarding the inquiry guide and the interview process
•    Strengthening the data collector’s knowledge of how their efforts fit into the larger process of assessment

Once each group had translated the questions to their satisfaction, they then presented their work to the other group for input and critical inquiry. From this process a consensus translation of the inquiry guide for data collection emerged. Then the data collectors, working with the leaders from the MOPDD, developed a strategy for data gathering and a list of targeted stakeholders from whom participation
in this process needed to be solicited. Once the data were collected, they were then translated into English for analysis.

Four districts were selected for testing the CEQ assessment tools, Burgesera, Kayonza, Nyaruguru, and Nyagatare. The first two represent districts with high levels of malaria. The latter two are districts with moderate to low levels of malaria. The MOPDD chose these districts not only because they represent differing levels of malaria incidence, but also because they vary in levels of intervention, particularly in efforts to develop CE. They range from no particular program of CE (Kayonza) to one with specific efforts to develop CE (Nyaruguru). Thus, the four districts offer varying contexts with respect to CE and malaria.

This process facilitates assessment that is culturally and contextually appropriate. The CEQ is designed to incorporate science-based principles regarding what data collection should assess, the process itself is developed within culture (in this case Rwanda) and context (in this case Malaria) following the same logic that recognizes the vital role of CE in improving health among various populations. This data should tell us more about the process of CE than any data collection thus far in Rwanda and most other locales. This is due to the different conceptual nature of the CEQ.