Prevalence and Factors Associated with Repeat Mental Health Service Utilization During Rwanda's Genocide Commemoration Week

1. Introduction

The yearly commemoration of the Rwandan Genocide holds profound significance, both historically and psychologically, for the nation and its people. Following the atrocities of 1994, Rwanda has grappled with enduring MH challenges among survivors and their descendants [1,2]. The trauma inflicted during this dark period continues to permeate Rwandan society, influencing attitudes, behaviors, and access to MH services [1]. Given the lingering impact of the genocide, understanding how individuals utilize MH services becomes imperative, given that people are still wrestling with unresolved trauma or heightened emotional distress [3]. Investigating the factors that shape MH service utilization is not only essential for addressing ongoing healthcare needs but also for fostering healing and resilience within the Rwandan community [4].

Recent research highlights the profound and persistent MH challenges faced by Rwandans since the 1994 genocide, with studies revealing high rates of posttraumatic stress disorder (PTSD) and depression, the intergenerational transmission of trauma, and significant psychological burdens on both survivors and their descendants [5,6,7,8]. These studies underscore the need for targeted MH interventions, especially as trauma impacts vulnerable groups differently, with findings pointing to gender-specific symptoms, increased risk of suicide, and unique psychological effects on rape survivors [9,10,11,12]. Additional insights revealed the cultural and societal complexities of MH within Rwandan families, illustrating how trauma is transmitted across generations, often limiting reconciliation efforts [13,14,15]. Research on Rwandan refugees in the U.S. emphasizes the need for culturally sensitive MH services to address stigma and access barriers [16].

Despite these significant contributions, there remains a gap in understanding the specific factors driving repeat MH service utilization. Existing studies have largely focused on the general prevalence and impact of PTSD, depression, and other MH disorders, but few have examined the factors associated with repeated service utilization during periods of intense remembrance and potential traumatization. This study aims to investigate the frequency and factors driving repeat MH service utilization during the genocide commemoration week in Rwanda.

2. Materials and Methods

The dataset utilized in this study was collected by MH professionals during the official week of the 2024 Rwandan Genocide commemoration. Individuals seeking MH support accessed services across various facilities, including health centers, district and provincial hospitals, and designated commemoration sites where counselors and psychologists were stationed to provide MH care. The dataset primarily focuses on essential demographic and contextual variables relevant to client assistance and support during the commemoration period. These variables include information such as gender, age, geographic location of service, and insurance coverage status.

Additionally, a key variable of interest is “MH service utilization,” which distinguishes between individuals seeking MH services for the first time during the genocide commemoration week and those with a history of service utilization during this week in previous years. This variable serves as the main focus of this study, particularly emphasizing patterns of MH support utilization during the genocide commemoration week, with a specific interest in individuals who repeatedly seek services during this sensitive period.

This study employed STATA 17 to conduct a comprehensive analysis of MH service utilization during genocide commemoration week. MH service utilization served as the main outcome variable, categorized as a binary variable with two levels: "first-time user" and "repeat user." The analysis began with descriptive statistics, summarizing the frequencies and percentages of individuals utilizing MH services during this period. This initial analysis provided a foundational understanding of the distribution of service use across various demographic and contextual variables. Chi-square tests and logistic regression analyses were employed to assess the statistical significance of factors influencing MH service utilization. Crude odds ratios (COR) and adjusted odds ratios (AOR), along with their respective p-values and 95 percent confidence intervals (95 percent-CI), were estimated. Gender, age, province, and insurance coverage were included as independent variables in the logistic regression model.

3. Results

A total of 825 individuals accessed MH services during Rwanda's 2024 genocide commemoration week. Of these, 76 percent (624 individuals) were identified as repeat users, while 24 percent (201 individuals) were first-time users, indicating a high prevalence of recurring MH needs during this period of remembrance.

Table 1 shows that a total of 825 participants were included, of whom 723 (87·6 percent) were female and 102 (12·4 percent) were male. The majority of participants were 31–50 years (57·3 percent), followed by those over 50 years (27·6 percent), while younger participants under 18 years and 18–30 years constituted smaller proportions (6·2 percent and 9·0 percent, respectively). Females were more represented across all age categories compared to males, except among those ages 50 and over years, where males accounted for 22·1 percent compared to 28·4 percent for females.

Geographically, most participants resided in Kigali City (33·4 percent), with slightly fewer participants from the Southern (24.7 percent), Northern/Western (20.6 percent), and Eastern (21.4 percent) provinces. Gender differences were observed, with males contributing a higher proportion of participants in Kigali City (45·1 percent) compared to females (31·7 percent).

In terms of insurance coverage, 9·2 percent of participants reported having health insurance, with males being slightly more likely to have coverage (13·7 percent) compared to females (8·5 percent). Among those without insurance, females accounted for 91·5 percent, reflecting their predominance in the study population.

Regarding MH service utilization, 24·2 percent of participants were first-time users and 75·8 percent were repeat users. The proportions of first-time and repeat users were similar across genders, with 23·5 percent of males and 24·3 percent of females being first-time users, while 76·5 percent of males and 75·7 percent of females were repeat users.

This distribution highlights the predominance of females in the sample and their greater engagement with MH services, as well as geographic and age-related variations in demographic and service utilization characteristics.

Table 2 shows the frequencies and prevalences of first-time and repeat MH service utilization stratified by gender, age, province, and insurance coverage, with associated CIs and p-values. The prevalence of first-time MH service utilization was almost similar between females (24·3 percent, 95 percent CI: 21·3–27·6) and males (23·5 percent, 95 percent CI: 16·3–32·7). Repeat utilization rates were also comparable, with females at 75·7 percent (95 percent CI: 72·4–78·7) and males at 76·5 percent (95 percent CI: 67·3–83·7), with no statistically significant difference between genders (p=0·858).

Age showed significant differences in utilization patterns (p<0· 001). First-time utilization was highest among participants under 18 years (34·0 percent, 95 percent CI: 22·0–48·6) and 18–30 years (46·4 percent, 95 percent CI: 35·0–58·1). In contrast, repeat utilization was most common among participants 31–50 years (77·2 percent, 95 percent CI: 73·0–81 ·0) and over 50 years (79·4 percent, 95 percent CI: 73·3–84·4), indicating that older individuals were more likely to be repeat users.

Geographic variations were observed, with the highest prevalence of first-time utilization in Kigali City (28·1 percent, 95 percent CI: 23·1–33 ·8), followed by the Southern (23·9 percent, 95 percent CI: 18·6–30·2), Northern/Western (21·8 percent, 95 percent CI: 16·3–28·4), and Eastern (21·8 percent, 95 percent CI: 16·3–28·4) provinces. Repeat utilization followed a similar trend, with Kigali City at 71·9 percent (95 percent CI: 66·2–76·9), though differences across provinces were not statistically significant (p=0·333).

Insurance coverage significantly influenced utilization patterns (p<0·001). First-time utilization was more common among participants with insurance (45·2 percent, 95 percent CI: 33·3–57·6) compared to those without insurance (21·3 percent, 95 percent CI: 18·3–24·6). Conversely, repeat utilization was higher among uninsured participants (78·7 percent, 95 percent CI: 75·4–81·7) than among those with insurance (54·8 percent, 95 percent CI: 42· 4–66·7).

Table 3 presents the prevalence of insurance coverage stratified by gender, age, province, and MH service utilization. Overall, only 9·3 percent (95 percent CI: 7·4–11·6) of participants were insured, indicating limited health insurance coverage among the study population. Gender-specific results showed slightly higher insurance coverage among males (13·7 percent, 95 percent CI: 8·1–22·2) compared to females (8·5 percent, 95 percent CI: 6·6–10·9). However, insured rates remained low in both genders.

Age-specific trends revealed that participants over 50 years had the lowest insured prevalence at 4·8 percent (95 percent CI: 2·5–9·0). Younger participants under 18 years and 18–30 years had slightly higher insured rates of 11·9 percent (95 percent CI: 5·0–25·6) and 11·3 percent (95 percent CI: 5·5–21·9), respectively. Participants ages 31–50 years also showed limited insurance coverage, with a prevalence of 11·4 percent (95 percent CI: 8·5–15·1).

Geographic differences were notable, with Kigali City having the highest insured prevalence at 27·9 percent (95 percent CI: 21·7–35·1). In contrast, participants from other provinces had substantially lower insurance coverage: 1·9 percent (95 percent CI: 0·7–4·9) in the Southern, 5·1 percent (95 percent CI: 2·6–9·4) in the Northern/Western, and 4·1 percent (95 percent CI: 2·0–8·3) in the Eastern provinces.

MH service utilization patterns showed higher insured prevalence among first-time users (16·9 percent, 95 percent CI: 11·9–23·4) compared to repeat users (6·2 percent, 95 percent CI: 4·5–8·6), suggesting that insurance may facilitate initial access to MH services.

These findings highlight consistently low insurance coverage across the population, with notable disparities by age, geographic location, and MH service utilization, particularly among older individuals and those residing outside Kigali City.

Table 4 displays the CORs and AORs with 95 percent CIs and p-values for factors associated with repeated MH service utilization.

Gender was not significantly associated with repeated service utilization. Compared to females, males had a COR of 1·1 (95 percent CI: 0·6–1·7, p=0·858) and an AOR of 1·3 (95 percent CI: 0·7–2·4, p=0·347).

Age showed significant associations in the adjusted model. Compared to participants under 18 years, those ages 31–50 years were significantly more likely to be repeat users (AOR: 2·3, 95 percent CI: 1·1–4 ·6, p=0·022). Participants over 50 years also demonstrated increased odds of repeat utilization, though this association was marginally significant (AOR: 2·0, 95 percent CI: 1·0–4·3, p=0·065). In contrast, participants ages 18–30 years had lower, though not statistically significant, odds of repeated utilization (AOR: 0·5, 95 percent CI: 0·2–2·2, p=0·143).

Geographic location showed no significant associations in either crude or adjusted models. Compared to participants from Kigali, those in the Southern (AOR: 0·9, 95 percent CI: 0·5–1·5, p=0·602), Northern/Western (AOR: 1·0, 95 percent CI: 0·6–1·8, p=0·923), and Eastern (AOR: 1.7, 95 percent CI: 0.9–3.1, p=0.086) provinces showed no strong evidence of differing odds of repeated utilization.

Insurance coverage was strongly associated with repeated MH service utilization. Participants without insurance had significantly higher odds of repeated utilization compared to those with insurance, with an AOR of 3·3 (95 percent CI: 1·8–6·2, p<0·001).

These findings underscore the role of insurance coverage and age in influencing repeated MH service utilization. Participants without insurance and those ages 31–50 years were more likely to engage in repeated utilization, while geographic and gender differences were not significant.

4. Discussion

The findings from this study provide a comprehensive view of the factors associated with repeat MH service utilization during Rwanda’s genocide commemoration week, revealing critical insights into the factors that influence ongoing MH support needs during this period of intense remembrance. A significant finding of this study is the high prevalence of repeat MH service users, comprising 76 percent of the total sample. This underscores the persistent and recurring nature of MH needs among individuals affected by the genocide, reflecting the long-term psychological impact of such traumatic events. The elevated rate of repeat utilization highlights the necessity for sustained MH interventions and support systems to address chronic MH conditions in this population.

This study offers unique insights into repeat MH service utilization during the genocide commemoration week, addressing a critical gap in understanding long-term MH needs. By collecting data from health centers, district hospitals, and provincial facilities nationwide, it captures a representative sample across diverse regions and demographics. Additionally, the study highlights vulnerable groups, such as middle-aged individuals and those without insurance, providing valuable information to inform future interventions and policies targeting these populations.

The study faced several limitations, including the lack of prior research on repeat MH service use during Rwanda's genocide commemoration week, limiting comparative analysis and broader conclusions. The absence of detailed data collection during follow-up visits restricts understanding of changes in MH status over time, and financial constraints limit the number of these visits, impacting continuous support. Additionally, the inability to link walk-in visits to repeat service use complicates continuity-of-care tracking, and a gender and district imbalance in the sample may affect the generalizability of findings. The intense emotional states of clients during the genocide commemoration week, along with the focus on immediate support, potentially impacted data completeness and reduced available variables for analysis, limiting the study's depth.

Gender did not emerge as a significant factor influencing repeat MH service utilization, with both males and females showing similar patterns of repeat use. This finding aligns with the broader literature that emphasizes the universal impact of traumatic events on MH across genders [14]. Age emerged as a notable factor, especially for middle-aged individuals (31–50 years), who demonstrated significantly higher odds of being repeat users compared to younger individuals. This finding suggests that middle-aged adults may face more severe or persistent MH challenges related to the genocide, underscoring a need for ongoing support. As reported in previous research, older individuals showed higher prevalence rates of PTSD and other MH disorders, which may be due to cumulative life stressors and prolonged trauma exposure [17]. The significant impact of age on service utilization mirrors studies that highlight the cumulative effect of trauma over the lifespan, particularly among middle-aged adults who lived through the genocide [17].

Geographical location, as indicated by the provinces of service within Rwanda, does not significantly impact the likelihood of repeat MH service use, reflecting the widespread availability of these services and the uniform impact of the genocide across different regions. However, as suggested by Eichelsheim, subtle regional variations might still exist, which were not captured in this study, due to the broad categorization of provinces [18].

Individuals without insurance were significantly more likely to be repeat users of MH services. Lack of insurance is a critical barrier to accessing and maintaining MH care. Uninsured individuals may face financial hardships that necessitate repeated use of available MH services during periods of crisis, such as the genocide commemoration week. Sabey et al. [19] reported that while decentralization and integration strategies increased care accessibility in a postgenocide Rwanda, a more collaborative, adaptive approach is essential to address local needs effectively and ensure equitable access to MH care. Persistent demand for MH services was reported previously by Rieder et al. [14] and Kagoyire et al. [13] that documented the long-term psychological effects of the genocide on survivors and their descendants. The critical barrier posed by lack of insurance coverage resonates with broader findings on the socioeconomic determinants of health and the importance of financial accessibility in maintaining MH care [19].

To improve MH service delivery during Rwanda's genocide commemoration week, it is recommended to enhance data collection during follow-up sessions by incorporating assessments of trauma severity and social support, thereby gaining deeper insights into factors contributing to repeat service utilization. Evaluating the effectiveness of current follow-up processes will help optimize intervention frequency and structure, ensuring they meet the specific needs. Expanding the role of community health workers in rural areas to conduct basic MH screenings and provide ongoing support can bridge service gaps in underserved regions. Additionally, increasing engagement efforts tailored to males and younger generations is crucial to address their unique MH needs effectively.

Future research should focus on examining urban-rural disparities in MH service access, investigating the MH needs of younger generations related to intergenerational trauma and conducting longitudinal studies to monitor MH service utilization over time. Additionally, collaboration with government agencies and NGOs is essential to secure funding and support for comprehensive follow-up programs.

5. Conclusions

This section is mandatory. This study highlights the significant and persistent need for MH services among individuals affected by Rwanda's 1994 genocide, particularly during the annual genocide against Tutsi commemoration week. The high prevalence of repeat service utilization, especially among middle-aged individuals and those without insurance, underscores the ongoing psychological impact and the barriers to accessing consistent MH care. These findings align with broader research on the long-term effects of trauma and the critical role of socioeconomic factors in MH service utilization. Addressing these needs through targeted interventions and improving healthcare or insurance coverage can enhance MH support systems, promoting resilience and well-being in the Rwandan community. This study contributes valuable insights for policy makers and healthcare providers, emphasizing the importance of comprehensive and accessible MH care during periods of intense national remembrance.