{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T22:21:55Z","timestamp":1792794115794,"version":"4.5.0"},"reference-count":35,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,1,27]],"date-time":"2025-01-27T00:00:00Z","timestamp":1737936000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,1,27]],"date-time":"2025-01-27T00:00:00Z","timestamp":1737936000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000054","name":"National Cancer Institute","doi-asserted-by":"publisher","award":["K07CA215819"],"award-info":[{"award-number":["K07CA215819"]}],"id":[{"id":"10.13039\/100000054","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Cancer"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Butaro Cancer Center of Excellence (BCCOE) was founded to serve Rwanda\u2019s rural low-income population, providing subsidized cancer diagnosis and treatment with transport stipends for the lowest-income patients. We examined whether travel distance to BCCOE was associated with advanced-stage diagnoses and treatment completion.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective cohort study using medical record data from BCCOE patients with pathologically-confirmed breast cancer from 2012\u20132016. Women with no prior surgery were included in the stage analysis; those with non-metastatic disease were included in the treatment analysis. We calculated travel distances using spatial analytic software and used multivariable logistic regression to examine the association of distance and other patient characteristics with late-stage diagnoses and treatment completion within one year of diagnosis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The analytic cohort for stage included 426 patients; 75.1% had late-stage (stage 3 or 4) disease. In univariable analyses, patients residing in BCCOE\u2019s surrounding district had a lower proportion of late-stage diagnoses compared to those residing outside the district (57.9% v 76.8%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.02). In adjusted analyses, odds of late-stage diagnosis were 2.46 (95% CI:1.21\u20135.12) times higher among those in distance quartile 4 (&gt;\u2009135.8 km) versus 1 (&lt;\u200955.7 km); the effect of distance was less strong in sensitivity analyses excluding patients from BCCOE\u2019s surrounding district. Patients from sectors with\u2009&gt;\u200950% poverty had 2.33 times higher odds of late-stage diagnoses (95% CI:1.07\u20135.26) relative to those with poverty\u2009&lt;\u200930%. In the treatment completion cohort (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009348), 49.1% of patients completed surgery and chemotherapy within a year. In adjusted analyses, travel distance and poverty were not linearly associated with treatment completion.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>At Rwanda\u2019s first public cancer facility, sector-level poverty and longer travel distances were associated with late-stage breast cancer diagnoses, but less clearly associated with treatment completion, perhaps partly due to travel stipends provided to the lowest-income individuals undergoing treatment. Our findings support further investigation into wider use of travel stipends to facilitate early diagnosis and treatment completion.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12885-025-13489-2","type":"journal-article","created":{"date-parts":[[2025,1,26]],"date-time":"2025-01-26T19:58:26Z","timestamp":1737921506000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["The association of travel distance and other patient characteristics with breast cancer stage at diagnosis and treatment completion at a rural Rwandan cancer facility"],"prefix":"10.1186","volume":"25","author":[{"given":"Kayleigh","family":"Bhangdia","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abirami","family":"Natarajan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Niclas","family":"Rudolfson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"St\u00e9phane","family":"Verguet","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcia C.","family":"Castro","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean-Marie Vianney","family":"Dusengimana","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cyprien","family":"Shyirambere","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lauren E.","family":"Schleimer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lawrence N.","family":"Shulman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aline","family":"Umwizerwa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Catherine","family":"Kigonya","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Butonzi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily","family":"MacDuffie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Temidayo","family":"Fadelu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel S.","family":"O\u2019Neil","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cam","family":"Nguyen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tharcisse","family":"Mpunga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nancy L.","family":"Keating","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lydia E.","family":"Pace","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,1,27]]},"reference":[{"issue":"1","key":"13489_CR1","doi-asserted-by":"publisher","first-page":"63","DOI":"10.1038\/sj.bjc.6604435","volume":"99","author":"A Gakwaya","year":"2008","unstructured":"Gakwaya A, Kigula-Mugambe JB, Kavuma A, Luwaga A, Fualal J, Jombwe J, et al. Cancer of the breast: 5-year survival in a tertiary hospital in Uganda. Br J Cancer. 2008;99(1):63\u20137.","journal-title":"Br J Cancer"},{"issue":"5","key":"13489_CR2","doi-asserted-by":"publisher","first-page":"571","DOI":"10.1634\/theoncologist.2015-0388","volume":"21","author":"LE Pace","year":"2016","unstructured":"Pace LE, Dusengimana J-MV, Hategekimana V, Habineza H, Bigirimana JB, Tapela N, et al. Benign and Malignant Breast Disease at Rwanda\u2019s First Public Cancer Referral Center. Oncologist. 2016;21(5):571\u20135.","journal-title":"Oncologist."},{"issue":"6","key":"13489_CR3","doi-asserted-by":"publisher","first-page":"739","DOI":"10.1634\/theoncologist.2015-0429","volume":"21","author":"LE Pace","year":"2016","unstructured":"Pace LE, Shulman LN. Breast Cancer in Sub-Saharan Africa: Challenges and Opportunities to Reduce Mortality. Oncologist. 2016;21(6):739\u201344.","journal-title":"Oncologist"},{"issue":"9","key":"13489_CR4","doi-asserted-by":"publisher","first-page":"e1203","DOI":"10.1016\/S2214-109X(20)30261-8","volume":"8","author":"V McCormack","year":"2020","unstructured":"McCormack V, McKenzie F, Foerster M, Zietsman A, Galukande M, Adisa C, et al. Breast cancer survival and survival gap apportionment in sub-Saharan Africa (ABC-DO): a prospective cohort study. Lancet Glob Health. 2020;8(9):e1203\u201312.","journal-title":"Lancet Glob Health"},{"issue":"10125","key":"13489_CR5","doi-asserted-by":"publisher","first-page":"1023","DOI":"10.1016\/S0140-6736(17)33326-3","volume":"391","author":"C Allemani","year":"2018","unstructured":"Allemani C, Matsuda T, Di Carlo V, Harewood R, Matz M, Nik\u0161i\u0107 M, et al. Global surveillance of trends in cancer survival 2000\u201314 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet. 2018;391(10125):1023\u201375.","journal-title":"Lancet"},{"issue":"6","key":"13489_CR6","doi-asserted-by":"publisher","first-page":"729","DOI":"10.1016\/S1470-2045(22)00198-X","volume":"23","author":"M Foerster","year":"2022","unstructured":"Foerster M, McCormack V, Anderson BO, Boucheron P, Zietsman A, Cubasch H, et al. Treatment guideline concordance, initiation, and abandonment in patients with non-metastatic breast cancer from the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort in sub-Saharan Africa: a prospective cohort study. Lancet Oncol. 2022;23(6):729\u201338.","journal-title":"Lancet Oncol"},{"key":"13489_CR7","doi-asserted-by":"publisher","unstructured":"Anderson BO, Ilbawi AM, Fidarova E, Weiderpass E, Stevens L, Abdel-Wahab M, et al. The Global Breast Cancer Initiative: a strategic collaboration to strengthen health care for non-communicable diseases. Lancet Oncol. 2021;22(5):578\u201381.\u00a0https:\/\/doi.org\/10.1016\/S1470-2045(21)00071-1. Epub 2021 Mar 7","DOI":"10.1016\/S1470-2045(21)00071-1"},{"issue":"9","key":"13489_CR8","doi-asserted-by":"publisher","first-page":"2212","DOI":"10.1002\/ijc.33400","volume":"148","author":"K Togawa","year":"2021","unstructured":"Togawa K, Anderson BO, Foerster M, Galukande M, Zietsman A, Pontac J, et al. Geospatial barriers to healthcare access for breast cancer diagnosis in sub-Saharan African settings: The African Breast Cancer\u2014Disparities in Outcomes Cohort Study. Int J Cancer. 2021;148(9):2212\u201326.","journal-title":"Int J Cancer"},{"issue":"9","key":"13489_CR9","doi-asserted-by":"publisher","first-page":"2173","DOI":"10.1002\/ijc.28861","volume":"135","author":"C Dickens","year":"2014","unstructured":"Dickens C, Joffe M, Jacobson J, Venter F, Sch\u00fcz J, Cubasch H, et al. Stage at breast cancer diagnosis and distance from diagnostic hospital in a periurban setting: a South African public hospital case series of over 1,000 women. Int J Cancer. 2014;135(9):2173\u201382.","journal-title":"Int J Cancer"},{"issue":"9","key":"13489_CR10","doi-asserted-by":"publisher","first-page":"1432","DOI":"10.1002\/cncr.33394","volume":"127","author":"GC Knapp","year":"2021","unstructured":"Knapp GC, Tansley G, Olasehinde O, Wuraola F, Adisa A, Arowolo O, et al. Geospatial access predicts cancer stage at presentation and outcomes for patients with breast cancer in southwest Nigeria: A population-based study. Cancer. 2021;127(9):1432\u20138.","journal-title":"Cancer"},{"key":"13489_CR11","unstructured":"University of Pennsylvania. Rwanda - Geography. East Africa Living Encyclopedia. https:\/\/www.africa.upenn.edu\/NEH\/rwgeography.htm\/.\u00a0Accessed 2 June 2023."},{"key":"13489_CR12","unstructured":"World Bank Group. Population, total - Rwanda. World Bank Open Data; 2022. https:\/\/data.worldbank.org\/indicator\/SP.POP.TOTL?locations=RW\/. Accessed 28 Aug 2023."},{"issue":"12","key":"13489_CR13","doi-asserted-by":"publisher","first-page":"815","DOI":"10.1038\/nrc3848","volume":"14","author":"LN Shulman","year":"2014","unstructured":"Shulman LN, Mpunga T, Tapela N, Wagner CM, Fadelu T, Binagwaho A. Bringing cancer care to the poor: experiences from Rwanda. Nat Rev Cancer. 2014;14(12):815\u201321.","journal-title":"Nat Rev Cancer"},{"issue":"8","key":"13489_CR14","doi-asserted-by":"publisher","first-page":"e405","DOI":"10.1016\/S1470-2045(15)00161-8","volume":"16","author":"S Stulac","year":"2015","unstructured":"Stulac S, Binagwaho A, Tapela NM, Wagner CM, Muhimpundu MA, Ngabo F, et al. Capacity building for oncology programmes in sub-Saharan Africa: the Rwanda experience. Lancet Oncol. 2015;16(8):e405\u201313.","journal-title":"Lancet Oncol"},{"key":"13489_CR15","doi-asserted-by":"publisher","unstructured":"Tapela NM, Mpunga T, Hedt-Gauthier B, Moore M, Mpanumusingo E, Xu MJ, Nzayisenga I, et al. Pursuing equity in cancer care: implementation, challenges and preliminary findings of a public cancer referral center in rural Rwanda. BMC Cancer. 2016;16:237.https:\/\/doi.org\/10.1186\/s12885-016-2256-7.","DOI":"10.1186\/s12885-016-2256-7"},{"key":"13489_CR16","doi-asserted-by":"publisher","unstructured":"Fadelu T, Nguyen C, Nsabimana N, Bigirimana E, Mukandayisenga V, Tuyishime V, et al. Abstract 67: Quantifying Transportation Barriers in Rwandan Patients Seeking Treatment for Breast Cancer. Cancer\u00a0Epidemiol Biomarkers\u00a0Prev. 2021;3(7):67.\u00a0https:\/\/doi.org\/10.1158\/1538-7755.Asgcr21-67.","DOI":"10.1158\/1538-7755.Asgcr21-67"},{"key":"13489_CR17","unstructured":"United Nations Office for the Coordination of Humanitarian Affairs. Rwanda - Subnational Administrative Boundaries Humanitarian Data Exchange. The Humanitarian Data Exchange. https:\/\/data.humdata.org\/dataset\/cod-ab-rwa\/. Accessed 3 Feb 2023."},{"key":"13489_CR18","unstructured":"ArcGIS. Open Street Map data for Rwanda.\u00a0https:\/\/www.arcgis.com\/home\/item.html?id=aa3f9b10f98844a088f1ba393b818648\/. Accessed\u00a03 Feb 2023."},{"key":"13489_CR19","unstructured":"ArcGIS. Rwanda 90 meters Digital Elevation Model.\u00a0https:\/\/hub.arcgis.com\/datasets\/dbe91ec91b7740bdbab44e29d2c954db\/.\u00a0Accessed 3 Feb 2023."},{"key":"13489_CR20","unstructured":"Google. Google Earth Engine; 2021. https:\/\/earthengine.google.com\/.\u00a0Accessed\u00a03 Feb 2023."},{"issue":"1","key":"13489_CR21","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1186\/1476-072X-11-40","volume":"11","author":"U Huerta Munoz","year":"2012","unstructured":"Huerta Munoz U, K\u00e4llest\u00e5l C. Geographical accessibility and spatial coverage modeling of the primary health care network in the Western Province of Rwanda. Int J Health Geogr. 2012;11(1):40.","journal-title":"Int J Health Geogr"},{"key":"13489_CR22","unstructured":"National Institute of Statistics Rwanda. Poverty Mapping Report 2013\u20132014. The Republic of Rwanda; 2017.\u00a0https:\/\/www.statistics.gov.rw\/publication\/poverty-mapping-report-2013-2014\/.\u00a0Accessed\u00a03 Feb 2023."},{"key":"13489_CR23","unstructured":"National Institute of Statistics Rwanda. Rwanda Poverty Profile Report - Results of EICV 4. The Republic of Rwanda; 2015.\u00a0https:\/\/www.statistics.gov.rw\/publication\/rwanda-poverty-profile-report-results-eicv-4\/.\u00a0Accessed 28 Aug 2023."},{"key":"13489_CR24","unstructured":"Deaton, A. Zaidi, S. Guidelines for constructing consumption aggregates for welfare analysis (English). Living standards measurement study (LSMS) working paper, no. LSM 135. World Bank Group; 2002. https:\/\/documents.worldbank.org\/en\/publication\/documents-reports\/documentdetail\/206561468781153320\/guidelines-for-constructing-consumption-aggregates-for-welfare-analysis\/."},{"key":"13489_CR25","unstructured":"Ministry of Local Government. Administrative Structure Rwanda: Government of Rwanda; 2023. Available from: https:\/\/www.gov.rw\/government\/administrative-structure."},{"key":"13489_CR26","doi-asserted-by":"publisher","unstructured":"Amin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK, et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more \"personalized\" approach to cancer staging. CA Cancer J Clin. 2017;67(2):93\u20139.\u00a0https:\/\/doi.org\/10.3322\/caac.21388. Epub 2017 Jan 17","DOI":"10.3322\/caac.21388"},{"key":"13489_CR27","doi-asserted-by":"publisher","first-page":"1446","DOI":"10.1200\/GO.20.00186","volume":"6","author":"LE Pace","year":"2020","unstructured":"Pace LE, Schleimer LE, Shyirambere C, Ilbawi A, Dusengimana JMV, Bigirimana JB, et al. Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process. JCO Glob Oncol. 2020;6:1446\u201354.","journal-title":"JCO Glob Oncol"},{"key":"13489_CR28","unstructured":"National Comprehensive Cancer Network. NCCN Harmonized Guidelines for Sub-Saharan Africa. NCCN Guidelines and Clinical Resources. 2017. Available from: https:\/\/www.nccn.org\/harmonized."},{"issue":"2","key":"13489_CR29","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0281916","volume":"18","author":"W Mapanga","year":"2023","unstructured":"Mapanga W, Norris SA, Craig A, Ayeni OA, Chen WC, Jacobson JS, et al. Drivers of disparities in stage at diagnosis among women with breast cancer: South African breast cancers and HIV outcomes cohort. PLoS ONE. 2023;18(2): e0281916.","journal-title":"PLoS ONE"},{"key":"13489_CR30","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1200\/JGO.19.11000","volume":"5","author":"LE Pace","year":"2019","unstructured":"Pace LE, Dusengimana JMV, Shulman LN, Schleimer LE, Shyirambere C, Rusangwa C, et al. Cluster Randomized Trial to Facilitate Breast Cancer Early Diagnosis in a Rural District of Rwanda. Journal of Global Oncology. 2019;5:1\u201313.","journal-title":"Journal of Global Oncology"},{"key":"13489_CR31","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1200\/JGO.17.00098","volume":"4","author":"LE Pace","year":"2018","unstructured":"Pace LE, Dusengimana JMV, Keating NL, Hategekimana V, Rugema V, Bigirimana JB, et al. Impact of Breast Cancer Early Detection Training on Rwandan Health Workers\u2019 Knowledge and Skills. Journal of Global Oncology. 2018;4:1\u201310.","journal-title":"Journal of Global Oncology"},{"key":"13489_CR32","doi-asserted-by":"publisher","unstructured":"Uwimana A, Dessalegn S, Vianney Dusengimana JM, Stauber C, Fata A, Hagenimana M, et a. Integrating Breast Cancer Early Detection Into a Resource-Constrained Primary Health Care System: Health Care Workers' Experiences in Rwanda. JCO Glob Oncol. 2022;8:e2200181.\u00a0https:\/\/doi.org\/10.1200\/GO.22.00181.","DOI":"10.1200\/GO.22.00181"},{"key":"13489_CR33","doi-asserted-by":"publisher","unstructured":"Pace LE, Fata AM, Cubaka VK, Nsemgiyumva T, Uwihaye JD, Stauber C, et al. Patients' experiences undergoing breast evaluation in Rwanda's Women's Cancer Early Detection Program. Breast Cancer Res Treat. 2023;202(3):541\u201350.\u00a0https:\/\/doi.org\/10.1007\/s10549-023-07076-x. Epub 2023 Aug 30","DOI":"10.1007\/s10549-023-07076-x"},{"issue":"7","key":"13489_CR34","doi-asserted-by":"publisher","first-page":"780","DOI":"10.1634\/theoncologist.2014-0493","volume":"20","author":"LE Pace","year":"2015","unstructured":"Pace LE, Mpunga T, Hategekimana V, Dusengimana JM, Habineza H, Bigirimana JB, et al. Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda. Oncologist. 2015;20(7):780\u20138.","journal-title":"Oncologist"},{"key":"13489_CR35","unstructured":"Local Administrative Entities Development Agency (LODA). Cabinet approves review and classification of households into Ubudehe categories2020. Available from: https:\/\/loda.prod.risa.rw\/updates\/news-detail\/cabinet-approves-review-and-classification-of-households-into-ubudehe-categories#:~:text=After%20reintroduction%20in%202001%2C%20the,%2C%20and%20(6)%20Abakire.\u00a0Cited 2024 September 10."}],"container-title":["BMC Cancer"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12885-025-13489-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12885-025-13489-2\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12885-025-13489-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,1,27]],"date-time":"2025-01-27T07:48:42Z","timestamp":1737964122000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmccancer.biomedcentral.com\/articles\/10.1186\/s12885-025-13489-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1,27]]},"references-count":35,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["13489"],"URL":"https:\/\/doi.org\/10.1186\/s12885-025-13489-2","relation":{},"ISSN":["1471-2407"],"issn-type":[{"value":"1471-2407","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,1,27]]},"assertion":[{"value":"17 November 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"10 January 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"27 January 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Ethical approval was obtained from the Partners HealthCare Institutional Review Board [2012P002016] (Boston, MA), the Rwanda National Ethics Committee (No 348\/RNEC\/2012), and the Harvard University Institutional Review Board [IRB20-0699] (Boston, MA). The requirement for informed consent from individuals whose medical records were reviewed for the study was waived.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"N\/A.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"146"}}