Challenges and Barriers in Accessing Health Services Among the Sudanese Community in Rwanda, 2024

Challenges and Barriers in Accessing Health Services Among the Sudanese Community in Rwanda, 2024 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenges and Barriers in Accessing Health Services Among the Sudanese Community in Rwanda, 2024 Taghwa Elfatih Mohamed Ali, Ahmed Hashim, Babiker Rahamtalla, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7664379/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Access to healthcare and equity are fundamental human rights. Rwanda, located in East Africa, has made significant progress in healthcare, economic growth and development efforts over the past few decades, since the national reconciliation that occurred post-genocide fighting. However, some challenges persist. The Sudanese community in Rwanda, mainly composed of refugees and migrants who fled war and Sudan instability and they face unique struggles due to their status and integration into Rwandan society. Hence, this study aims to raise awareness towards the challenges and barriers to address these challenges and barriers to ease accessing the healthcare services in Rwanda. Methods : This descriptive community-based cross-sectional study was carried out on a sample of 103 participants, they were selected through convenience sampling technique. Participants were selected based on their availability and willingness to participate. Data collected through an online questionnaire and Google form used to spread the questionnaire. Data obtained analyzed using Statistical Package for the Social Sciences 25 (SPSS), then the results presented by tables and charts. Results : The study recruited 102 Sudanese participants, majority (54.9%) were female and 45.1% male. Most participants were aged 18-26. Out of the 102 participants, only one (1) participant did not have legal permission to reside in Rwanda, and data of 102 participants analyzed. All participants were native Arabic speakers, with only 4.9% able to speak French and Kinyarwanda, the languages predominantly used in Rwanda. Language barriers were reported by 21.7% of participants, and 20.8% faced difficulties with transportation. The most reported difficulty was long waiting times to access healthcare services, followed by high service costs (23.8%). Additionally, 45% of participants visited healthcare facilities for illness or injury, while 24.5% visited for routine check-ups. Conclusion : The Sudanese community in Rwanda faced significant challenges in accessing healthcare services due to long waiting times, high service costs, and language barriers. These findings highlight the need to raise awareness and develop inclusive healthcare policies that address these specific needs. Identifying barriers for accessing healthcare is crucial for informing policy- makers to create or develop some programs that would offer culturally appropriate, patient-centered care for the refugee community. In addition, these findings underscore the necessity for an increased support for both refugees and healthcare providers to enhance language proficiency and cultural competency. Hospital Medicine Health Policy Health Economics & Outcomes Research Sudanese community in Rwanda health care services challenges and barriers language barriers migrants Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction 1.1 Background: - 1.1.1 Access to Health Services: Healthcare services are crucial for maintaining public health for both natives and foreign residents, including refugees, without facing challenges or barriers. Access to healthcare services is a significant factor in determining health outcomes and overall well-being. It encompasses the availability, accessibility, and affordability of healthcare, all of which are essential for achieving universal healthcare coverage (UHC). Barriers to obtaining health services can result in unmet healthcare needs, delays in receiving adequate care, and increased morbidity and mortality (1). Globally, variations in access to healthcare are evident among different communities, often influenced by socioeconomic class, geographical location, and cultural factors (2). The World Health Organization highlights that equitable access to healthcare is a fundamental human right and critical for sustainable development (3). Many low- and middle-income countries, such as Rwanda, face a variety of barriers and challenges in accessing healthcare, particularly for vulnerable communities such as refugees, migrants, and marginalized ethnic groups (4). 1.1.2 Sudanese Community in Rwanda: The Sudanese community in Rwanda is one of many migrant groups living in Rwanda due to a variety of sociopolitical and economic reasons. Migration often presents issues related to integration and access to essential services, including healthcare (5). The Sudanese community in Rwanda faces specific barriers as they adapt to a new cultural and healthcare context, including potential language barriers, discrimination, and difficulties with the local healthcare system (6). According to current research, migrant communities, particularly the Sudanese, often experience significant health inequalities compared to the native population, primarily due to these barriers and challenges (7). Additionally, the impact of past trauma, financial instability, and social isolation has complicated their ability to access necessary healthcare services (8). 1.1.3 Barriers to Accessing Health Services: A variety of issues can make it difficult to access healthcare, especially for migrant populations. These barriers are frequently classified into structural, financial, and societal categories (9). Structural barriers include inadequate healthcare infrastructure, long distances to health facilities, and limited healthcare personnel. Financial barriers encompass the cost of healthcare services, including consultation fees, medication costs, and transportation expenses (10). Socio-cultural hurdles involve linguistic disparities, levels of health literacy, and beliefs that may conflict with medical care (11). 1.1.4 Health Services in Rwanda: Rwanda has made significant progress in upgrading its healthcare system over the last two decades. The country has implemented policies aimed at improving access to healthcare through initiatives such as community-based health insurance (CBHI) and the development of health clinics across the nation (12). Despite these improvements, discrepancies in access to health services persist, particularly for vulnerable populations like the Sudanese community (13). Understanding the specific challenges faced by this community is crucial for developing targeted interventions that can enhance their access to healthcare and, consequently, their overall health and well-being (14). This study aims to investigate the challenges and barriers encountered by the Sudanese community in Rwanda in accessing health services, with the goal of informing policies and interventions that can improve health equity. 1.2 Problem statement: Accessing health services is a major issue for the Sudanese community in Rwanda, as shown by earlier studies and personal reports that point out significant challenges and barriers. These problems delay healthcare delivery and worsen health disparities. Although there have been efforts to improve access, the specific issues affecting Sudanese people in Rwanda are not well resolved. Therefore, it is crucial to thoroughly investigate these challenges to develop targeted solutions and policies that can improve healthcare access and fairness for the Sudanese community in Rwanda. 1.3 Justification: This study aims to explore the barriers face the Sudanese community in Rwanda in accessing healthcare services, particularly in the context of their migration due to socio-political factors. The study is important for several reasons to assess the healthcare services and awareness, also to identify and investigate the real barriers to healthcare services utilization. Importance of this study is timely aiming to promote equitable healthcare services in order to improve healthcare outcomes. 1.4 Research question: What are the challenges and barriers in accessing healthcare services among the Sudanese community in Rwanda in 2024? 1.5 Research hypotheses: 1.5.1 Alternative Hypothesis (H1): The Sudanese community in Rwanda faces significant barriers to accessing healthcare services due to factors such as language difficulties, economic constraints, legal residency issues, and cultural differences. This negatively impact their healthcare utilization and outcomes. 1.6 Research objectives: - 1.6.1 General Objective: - To determine the challenges and barriers in accessing the health care among the Sudanese community in Rwanda. 1.6.2 Specific Objectives: To describe the sociodemographic characteristic of the Sudanese community in Rwanda. To analyze immigration related barriers to health care services. To determine the communication barriers in accessing health care services. To determine the financial barriers in accessing health care services. To assess the utilization of health care services. 2. Literature Review A study done by Owoaje et al. emphasized that access to health services is a fundamental right, yet numerous challenges and barriers can impede this access, particularly among migrant communities such as the Sudanese in various host countries. Understanding these challenges is crucial for improving health outcomes and ensuring equitable healthcare provision. The study highlighted several barriers faced by migrant communities in accessing health services, including language barriers, cultural differences, and lack of familiarity with the healthcare system [15]. A study done by Blessing Kanengoni-Nyatara, Kathleen B., Carolina, Nadia A., and Charles investigated access to healthcare for migrants and refugees in Aotearoa, New Zealand. The studies discovered that migrants and refugees face challenges in receiving healthcare due to a number of overlapping variables. Three primary issues were identified: attitudinal barriers, structural barriers, and the need for recommendations to increase access to healthcare in different situations. Most studies reported a lack of sensitivity among medical professionals to the cultural backgrounds of migrant and refugee patients, as well as discrimination by healthcare providers. Participants from migrant, refugee, and refugee-like backgrounds shared experiences of rejection in both primary and secondary healthcare settings [16]. A follow-up study by Blessing Kanengoni-Nyatara, Kathleen B., Carolina, Nadia A., and Charles in 2024 investigated access to healthcare for migrants and refugees in Aotearoa, New Zealand. The dominant issue across most studies was language barriers and their consequences in exploring, collecting, and using healthcare services for migrants and refugees. As stated by Jayan and Dutta, multiple organizations lacked access to easily translated material on COVID-19 or support services, aggravating the problem [16]. A study conducted by Judith, Isabella, and Bernhard in 2019 compared health outcomes between Austrians and refugees. Findings from the Refugee Health and Integration Survey (ReHIS) showed that one in three women assessed their health as “very good,” while 18% rated it as “not good.” Among men, 42% rated their health as “very good,” and 14% as “not good.” Self-rated health (SRH) results suggested that the increased use of hospital emergency treatments was partly due to a lack of information about available general practitioners and specialists. Accessibility issues were also noted, with refugees consulting dentists far less frequently than Austrians. This demonstrates that, despite the high demand for treatment, migrants face limited access to information. They also experience greater difficulties arranging appointments and paying for treatments. Specialty services such as dental care and physiotherapy often require co-payments, creating hidden cost burdens that discourage preventive and primary care. Overall, the study emphasized that knowledge of and access to primary healthcare professionals should be improved to reduce reliance on emergency departments, which would also reduce costs. Providing trained interpreters, including online translators, can help overcome language barriers. The authors further advocated for implementing policies to promote refugee integration into the healthcare system at all levels, addressing both language and socio-cultural challenges. The study also found that nine in ten men and all women surveyed in ReHIS had consulted a healthcare provider (physician or specialist) in 2018, but specialists were less often consulted by refugees compared to Austrians [17]. A study conducted by Zaid, Eyup, and Gurel in 2018 investigated Syrian refugees in Turkey. Participants reported financial challenges that limited business growth, including restricted access to banking, rigid bank procedures, high tax rates, limited capital mobility, and inadequate facilities [18]. A study conducted by Kuan Ai Seon, Chen Tzeng-Ji, and Lee Wui-Chiang in 2017 in Taiwan showed that the vast majority of migrants in Taiwan (91.9%) were covered by the country’s universal National Health Insurance (NHI). At the time, there were approximately 720,000 international migrants (54.5% women). Study participants reported three main barriers to healthcare in Taiwan: language and information, sociocultural and economic factors, and policy and resource limitations [19]. A study conducted by Ana P., Ifna, Xiao, Sylvia, and Félice in 2018 used cross-sectional survey data in Tijuana, Mexico, to investigate access to health services among Mexican immigrants and migrants to the U.S. across migration phases, including pre-departure, destination, interception, and return. The findings indicated that immigrants’ access to healthcare decreased after the pre-departure phase. This was demonstrated by significantly reduced opportunities to obtain healthcare and secure a regular source of care, as well as higher odds of reporting foregone care during the destination, interception, and return phases compared to the pre-departure phase [20]. A 2018 study by Katongole S.P., Namaganda S., Baryamureeba B., et al. in Uganda investigated barriers to healthcare access for refugees in settlements using a mixed-methods approach that included surveys and interviews with both refugees and healthcare providers. The study found that 62% of refugees encountered challenges in accessing healthcare due to long wait times and insufficient medical supplies (p < 0.01). Additionally, 55% cited transportation issues, such as the lack of affordable options, as a major obstacle to reaching healthcare facilities (p < 0.01). Furthermore, 50% of refugees had limited awareness of available health services, leading to delays in seeking care (p < 0.05) [21]. 3. METHODOLOGY 3.1 Study Design: A cross-sectional community-based study. 3.2 Study Area: The study was conducted within the Sudanese community in Kigali, the capital city of Rwanda, located in East Africa, Rwanda is known for its post-genocide rehab and development efforts during the last few decades. Rwanda, nicknamed the "Land of a Thousand Hills," is famous for its conservation efforts and unusual recovery from the 1994 genocide. Despite these advancements, barriers to healthcare access remain, particularly for immigrant communities such as the Sudanese. 3.3. Study population: The study population included Sudanese individuals in Rwanda, specifically those aged 18 years and older, from various backgrounds and reasons for settling in Rwanda. There was no accurate statistic of the number of Sudanese in Rwanda at the time of the data collection so the exact size of population was unknown. 3.4 Sampling: 3.4.1 Sampling technique: Convenience sampling technique was used, where participants were selected based on their availability and willingness to participate through internet access. This technique was chosen because access to the study population was limited, and the resources for sampling were constrained. 3.4.2 Sample size: The sample size was determined by the number of Sudanese people in Rwanda. One hundred and two (102) participated who were able to respond to the online survey. 3.3.1 Inclusion criteria: Sudanese Individuals whose nationality based on Sudanese origin Sudanese people who are currently living in Rwanda, regardless of their legal status Include the ages between 18 years and above. 3.3.2 Exclusion criteria: Non-Sudanese Individual s. Sudanese individuals under 18 years old. Sudanese Individuals participated from Outside of Rwanda. Individuals who are unable to communicate effectively or not understand Arabic and English Questionnaire Participants who were unwilling to participate. 3.5 Data Collection tool: Data was collected using an online questionnaire shared by WhatsApp taken from previous research [17,19 ,20] and the questionnaire was formulated to fit the research objectives. The questionnaire was written in English then translated to Arabic. The questionnaire assessed of the following domains: sociodemographic profile Immigration characteristics. Access to Health Services. Utilization of Health Services. 3.6 Data Management and Analysis: Data was entered and analyzed to Microsoft Excel sheet and protected with password. Analysis done for data of 102 participants, Analysis done on the statistical package for social sciences (SPSS) version 25. P value of 0.05 will be used as cutoff point of statistical significance for independent-sample t-test and associations between two categorical variables were assessed using the chi-square test. To describe our study population, we used frequency tables, bar charts, pie charts, graphs, percentage, means, and standard deviation. 3.7 Ethical Considerations: Permission and approval were obtained from the research technical and ethical committee at the Faculty of Medicine, University of Medical Sciences and Technology. All the data were kept in a private folder, and weren’t spread or used in any other purpose. Research purposes and objectives were explained to participants in clear simple words and verbal consent was obtained from each participant. They were also notified about their rights to withdraw at any time without any deprivation. 4 RESULTS 4.1 Socio-Demographic Data: Table 4.1: shows the socio-demographic data among the participants (N = 102). Out of 102 participants in this study, the majority were females {54.9%} aged from 18 to 26 years old {94.8%} and they were single {98%}. Moreover, most of the participants were at university level {93.1%}. Finally, most of the participants were in Rwanda for less than one year and {55.9%} had residency. 4.1.1 Language: This study found that all the participants could speak Arabic {100%} and most of them could speak English {97%} while a few could speak French or Kinyarwanda {4.9%}. 4.1.2. Insurance Assessment: Table 4.2: shows the insurance assessment among the participants (N = 102) In this study, only {16.7%} had a medical insurance and {11.8%} were private insurance. 4.2 Access to Health services: Table 4.3: shows the assessment of health services access among the participants (N = 102) Most of the participants rated their health as very good {34.3%}, they were aware of the available health services in Rwanda {65.7%} and {54.9%} went to get these healthcare services in Rwanda. Moreover, most of the participants were naturally satisfied with these services {53.7%} and {46.1%} were naturally communicating 4.2.1 Healthcare services in Rwanda: Most of the participants in this study chose hospital {30.4%} and PHC {21.6%} as their destination to access health services. 4.3 Difficulties: This study found that the most common difficulties that faced the participants in accessing health services were long waiting time {24.8%}, high cost of the services {23.8%}, language barriers {21.7%} and transportation {20.8%}. 4.4Utilization of Health Services: Table 4.4: shows the utilization of health services among the participants (N = 102) Concerning utilization of health services, most of the participants went to these facilities one to two times per year {38.2%} and the majority went to PHC facilities {33.3%}. Moreover, {42.2%} of the participants did delay their seeking healthcare services in Rwanda and {51%} were dissatisfied with the quality of healthcare services received in Rwanda. 4.4.1 Primary Reasons for Visiting Healthcare Facilities: This study found that illness / injury was the commonest reason for visiting health facilities among the participants {45%} followed by routine checkups {24.5%}. 4.5 Associations: Table 4.5: shows the association between access to health and influencing factors among the participants (N = 102). In this study the only significant association was between access to health and transportation, P value < 0.05 {0.023} 5 DISCUSSION Healthcare services are a fundamental human right for maintaining public health, both for native and foreign residents of a country. Foreigners in different countries face various challenges regardless of the reasons for settling. This study examined healthcare access among Sudanese people in Rwanda and explored the challenges and barriers they face. This study was conducted on Sudanese people living in Rwanda, with a sample size of 102 participants in 2024, with the following significant findings: Regarding the sociodemographic data, most participants were aged between 18–26 years, and the majority were female. More than two-thirds of participants had been residing in Rwanda for less than one year. This may explain why many participants were unaware of available health services, as they had only recently settled in Rwanda. With respect to healthcare services, hospital services (inpatient and outpatient) and primary healthcare services were the most commonly accessed by participants. This finding aligns with the study conducted by Kuan, Ai Seon; Chen, Tzeng-Ji; and Lee, Wui-Chiang, which reported that about one-third of ReHIS respondents received hospital treatment during the last 12 months, with hospital daycare being more frequent [19]. Among the participants, 34.3% assessed their health as “very good,” while 65.7% were aware of the availability of health services. The increased reliance on hospital emergency services may be partly due to a lack of information about available general practitioners and specialists. This finding is consistent with the study by Kanengoni-Nyatara, B., Watson, K., Galindo, C., et al. [16]. Long waiting times were identified by 84.7% of participants as the most critical structural barrier to accessing healthcare. This indicates a systemic problem within the healthcare system that disproportionately impacts migrant populations. These findings are consistent with the study conducted by Owoaje et al. [15], which highlighted similar structural barriers in host countries, where migrants frequently endure extended waiting times, often worsened by their non-national status. Similarly, this reflects the experience of the Sudanese community, who encounter delays in accessing care. Language was identified as another major barrier, with 83.7% of participants citing it as a significant challenge. Only 4.9% of participants were able to speak French or Kinyarwanda, highlighting a serious communication gap that hinders effective access to healthcare. This result aligns with the study by Kanengoni-Nyatara et al. in Aotearoa [16], which identified language as the most significant barrier to healthcare access for migrants and refugees. Likewise, the study conducted in Taiwan by Kuan Ai Seon et al. [19] emphasized how limited language proficiency obstructs healthcare access, often leading to misunderstandings and lower quality of care. The lack of interpreters or bilingual healthcare providers further exacerbates the issue, making it difficult for the Sudanese community to navigate the healthcare system, understand medical advice, and express health concerns. These findings are consistent with global trends, where language barriers are a common obstacle to quality healthcare for migrant communities. Financial barriers were also prominent, with 69.1% of participants citing the high cost of healthcare as a major challenge. Additionally, only 15% of participants had health insurance, limiting their access to affordable services. This is in agreement with the study by Kuan Ai Seon et al. [19], which reported that high costs were a major barrier to healthcare access among migrants in Taiwan. Low health insurance coverage forces many migrants to pay out-of-pocket, discouraging them from seeking care and leading to delayed or missed treatments. These findings reinforce global evidence that financial challenges represent a substantial barrier to healthcare access among migrants. The study also identified a significant association between access to healthcare and transportation, with a p-value of 0.023, indicating that transportation plays a crucial role in determining healthcare accessibility for the Sudanese community in Rwanda. Difficulties in accessing reliable and affordable transportation can hinder medical care, leading to missed appointments, delayed treatment, and reduced utilization of healthcare services. This finding is consistent with the study conducted by Katongole S.P., Namaganda S., Baryamureeba B., et al. [21], in which 55% of refugees identified transportation issues—particularly the lack of affordable options—as a major barrier to accessing healthcare facilities (p < 0.01). Limitations: There are several limitations to consider in this study. The sample was not distributed equally among the Sudanese community and may not represent the studied populations in Rwanda, which might affect outcomes of the current study. Abbreviations community-based health insurance (CBHI) universal health coverage (UHC) Refugee Health and Integration Survey (ReHIS) self-rated health (SRH) National Health Insurance (NHI) Declarations Dedications This research is dedicated to my father, my first and last supporter—may Allah have mercy on him; my mother, the strongest woman and the source of my strength in this life; to Mohammed and Arwa, my role models who have always been supportive, helpful, and present for me; to my cousin Asma, who took care of me all the time; thank you to my uncle, Ahmed, Mahmood, and Salwa, and all my uncles and aunts; and to my friends, Areej, Rahaf ,Manhal, Aseel, Shahad, Mawada, Istifaa ,Fajr, Nihad and Tayseer. Full acknowledge from the deepest part of my heart for unlimited support and being nice partners in this journey and make it easier for me. Acknowledgment: I would like to thank my supervisor Dr. Babiker Mohammed Ali from the bottom of my heart, for his contribution to this research, and for my co-supervisor Abeer Ahmed for her guidance and helping me, I would like to thank my dearest uncle Dr. Ahmed Mohammed Ali, Ammar Srar, D.r Moez for their efforts with me and Dr. Ahmed Abdulrahman for everything. References World Health Organization. Universal health coverage (UHC) [Internet]. 2020 [cited 2024 Aug 8]. Available from: https://www.who.int/news-room/fact-sheets/detail/universal- health-coverage-(uhc) Marmot M. The health gap: the challenge of an unequal world. The Lancet. 2015;386(10011):2442-4. World Health Organization. Human rights and health [Internet]. 2017 [cited 2024 Aug 8]. 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BMJ. 2013;346 The right to health [Internet]. www.who.int. Available from: https://www.who.int/tools/your-life-your-health/know-your-rights/the-right-to-health Kanengoni-Nyatara, B., Watson, K., Galindo, C. et al. Barriers to and Recommendations for Equitable Access to Healthcare for Migrants and Refugees in Aotearoa, New Zealand: An Integrative Review. J Immigrant Minority Health 26 , 164–180 (2024). https://doi.org/10.1007/s10903-023-01528-8 Kohlenberger, Judith, et al. “Barriers to Health Care Access and Service Utilization of Refugees in Austria: Evidence from a Cross-Sectional Survey.” Health Policy , vol. 123, no. 9, Sept. 2019, pp. 833–839, www.sciencedirect.com/science/article/pii/S0168851018305335, https://doi.org/10.1016/j.healthpol.2019.01.014. Alrawadieh, Zaid, et al. “Understanding the Challenges of Refugee Entrepreneurship in Tourism and Hospitality.” The Service Industries Journal , vol. Kuan, Ai Seona,b; Chen, Tzeng-Jic,d,e; Lee, Wui-Chiange,f,*. Barriers to health care services in migrants and potential strategies to improve accessibility: A qualitative analysis. Journal of the Chinese Medical Association 83(1): p 95-101, January 2020. | DOI: 10.1097/JCMA.0000000000000224 Martinez-Donate, Ana P., et al. “Access to Health Care among Mexican Migrants and Immigrants: A Comparison across Migration Phases.” Journal of Health Care for the Poor and Underserved , vol. 28, no. 4, 2017, pp. 1314–1326, https://doi.org/10.1353/hpu.2017.0116. Katongole SP, Namaganda S, Baryamureeba B, et al. Barriers to healthcare access among refugees in Uganda. BMC Health Services Research. 2018;18(1): 508. Additional Declarations The authors declare no competing interests. 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.\u003c/p\u003e","description":"","filename":"41.png","url":"https://assets-eu.researchsquare.com/files/rs-7664379/v1/e96042aa425bebeda8dcf473.png"},{"id":91977553,"identity":"89801fa9-8a23-4a56-afb1-1c5a5c50fa6a","added_by":"auto","created_at":"2025-09-23 10:21:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":327415,"visible":true,"origin":"","legend":"\u003cp\u003eshows the common health services accessed by the participants (N = 102)\u003c/p\u003e","description":"","filename":"42.png","url":"https://assets-eu.researchsquare.com/files/rs-7664379/v1/8bdc13d22d5085a8c175c13f.png"},{"id":91977552,"identity":"b2f55128-aaf7-42b8-a5f6-88877c4367b5","added_by":"auto","created_at":"2025-09-23 10:21:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":343765,"visible":true,"origin":"","legend":"\u003cp\u003eshows the difficulties in accessing health services among the participants (N = 102).\u003c/p\u003e","description":"","filename":"43.png","url":"https://assets-eu.researchsquare.com/files/rs-7664379/v1/a66db8c09d4949b6f3fa8a16.png"},{"id":91977551,"identity":"45deeb7f-cab4-445b-b139-e69e9dedcbb1","added_by":"auto","created_at":"2025-09-23 10:21:38","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":159012,"visible":true,"origin":"","legend":"\u003cp\u003eshows Primary Reasons for Visiting Healthcare Facilities among the participants (N = 102)\u003c/p\u003e","description":"","filename":"44.png","url":"https://assets-eu.researchsquare.com/files/rs-7664379/v1/8e0c5bdcdefe52657b4b0519.png"},{"id":91979018,"identity":"914f9576-49d6-4377-acee-f7e3206d3ec0","added_by":"auto","created_at":"2025-09-23 10:37:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2916143,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7664379/v1/b4a40e0d-d17c-43ee-906c-5f6c34672a63.pdf"},{"id":91978715,"identity":"db6c8ce2-62e4-43e1-92ad-fa5010664d9f","added_by":"auto","created_at":"2025-09-23 10:29:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":984261,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-7664379/v1/4445726a34e7ffd2d7402f69.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eChallenges and Barriers in Accessing Health Services Among the Sudanese Community in Rwanda, 2024\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003e\u003cstrong\u003e1.1 Background: -\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.1.1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAccess to\u0026nbsp;Health\u0026nbsp;Services:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare services are crucial for maintaining public health for both natives and foreign residents, including refugees, without facing challenges or barriers. Access to healthcare services is a significant factor in determining health outcomes and overall well-being. It encompasses the availability, accessibility, and affordability of healthcare, all of which are essential for achieving universal healthcare coverage (UHC). Barriers to obtaining health services can result in unmet healthcare needs, delays in receiving adequate care, and increased morbidity and mortality (1). Globally, variations in access to healthcare are evident among different communities, often influenced by socioeconomic class, geographical location, and cultural factors (2). The World Health Organization highlights that equitable access to healthcare is a fundamental human right and critical for sustainable development (3). Many low- and middle-income countries, such as Rwanda, face a variety of barriers and challenges in accessing healthcare, particularly for vulnerable communities such as refugees, migrants, and marginalized ethnic groups (4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.1.2 Sudanese Community in Rwanda:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Sudanese community in Rwanda is one of many migrant groups living in Rwanda due to a variety of sociopolitical and economic reasons. Migration often presents issues related to integration and access to essential services, including healthcare (5). The Sudanese community in Rwanda faces specific barriers as they adapt to a new cultural and healthcare context, including potential language barriers, discrimination, and difficulties with the local healthcare system (6). According to current research, migrant communities, particularly the Sudanese, often experience significant health inequalities compared to the native population, primarily due to these barriers and challenges (7). Additionally, the impact of past trauma, financial instability, and social isolation has complicated their ability to access necessary healthcare services (8).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.1.3 Barriers to Accessing Health Services:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA variety of issues can make it difficult to access healthcare, especially for migrant populations. These barriers are frequently classified into structural, financial, and societal categories (9). Structural barriers include inadequate healthcare infrastructure, long distances to health facilities, and limited healthcare personnel. Financial barriers encompass the cost of healthcare services, including consultation fees, medication costs, and transportation expenses (10). Socio-cultural hurdles involve linguistic disparities, levels of health literacy, and beliefs that may conflict with medical care (11).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;1.1.4 Health Services in Rwanda:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRwanda has made significant progress in upgrading its healthcare system over the last two decades. The country has implemented policies aimed at improving access to healthcare through initiatives such as community-based health insurance (CBHI) and the development of health clinics across the nation (12). Despite these improvements, discrepancies in access to health services persist, particularly for vulnerable populations like the Sudanese community (13). Understanding the specific challenges faced by this community is crucial for developing targeted interventions that can enhance their access to healthcare and, consequently, their overall health and well-being (14). This study aims to investigate the challenges and barriers encountered by the Sudanese community in Rwanda in accessing health services, with the goal of informing policies and interventions that can improve health equity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 Problem statement:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccessing health services is a major issue for the Sudanese community in Rwanda, as shown by earlier studies and personal reports that point out significant challenges and barriers. These problems delay healthcare delivery and worsen health disparities. Although there have been efforts to improve access, the specific issues affecting Sudanese people in Rwanda are not well resolved. Therefore, it is crucial to thoroughly investigate these challenges to develop targeted solutions and policies that can improve healthcare access and fairness for the Sudanese community in Rwanda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3 Justification:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aims to explore the barriers face the Sudanese community in Rwanda in accessing healthcare\u0026nbsp;services,\u0026nbsp;particularly\u0026nbsp;in\u0026nbsp;the\u0026nbsp;context\u0026nbsp;of\u0026nbsp;their\u0026nbsp;migration\u0026nbsp;due\u0026nbsp;to\u0026nbsp;socio-political\u0026nbsp;factors. The\u0026nbsp;study\u0026nbsp;is\u0026nbsp;important\u0026nbsp;for\u0026nbsp;several\u0026nbsp;reasons\u0026nbsp;to\u0026nbsp;assess\u0026nbsp;the\u0026nbsp;healthcare\u0026nbsp;services\u0026nbsp;and\u0026nbsp;awareness,\u0026nbsp;also to\u0026nbsp;identify\u0026nbsp;and\u0026nbsp;investigate\u0026nbsp;the\u0026nbsp;real\u0026nbsp;barriers\u0026nbsp;to\u0026nbsp;healthcare\u0026nbsp;services\u0026nbsp;utilization.\u0026nbsp;Importance\u0026nbsp;of\u0026nbsp;this study\u0026nbsp;is\u0026nbsp;timely\u0026nbsp;aiming\u0026nbsp;to\u0026nbsp;promote\u0026nbsp;equitable\u0026nbsp;healthcare\u0026nbsp;services\u0026nbsp;in\u0026nbsp;order\u0026nbsp;to\u0026nbsp;improve\u0026nbsp;healthcare outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.4 Research question:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhat are the challenges and barriers in accessing healthcare services among the Sudanese community in Rwanda in 2024?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.5 Research hypotheses:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.5.1 Alternative Hypothesis (H1):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Sudanese community in Rwanda faces significant barriers to accessing healthcare services\u0026nbsp;due\u0026nbsp;to\u0026nbsp;factors\u0026nbsp;such\u0026nbsp;as\u0026nbsp;language\u0026nbsp;difficulties,\u0026nbsp;economic\u0026nbsp;constraints,\u0026nbsp;legal\u0026nbsp;residency issues, and cultural differences. This negatively impact their healthcare utilization and outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;1.6 Research objectives: -\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.6.1\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eGeneral Objective:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine the challenges and barriers in accessing the health care among the Sudanese community in Rwanda.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.6.2 Specific Objectives:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eTo describe the sociodemographic characteristic of the Sudanese community in Rwanda.\u003c/li\u003e\n \u003cli\u003eTo\u0026nbsp;analyze\u0026nbsp;immigration\u0026nbsp;related\u0026nbsp;barriers\u0026nbsp;to\u0026nbsp;health\u0026nbsp;care\u0026nbsp;services.\u003c/li\u003e\n \u003cli\u003eTo\u0026nbsp;determine\u0026nbsp;the communication\u0026nbsp;barriers\u0026nbsp;in\u0026nbsp;accessing\u0026nbsp;health\u0026nbsp;care\u0026nbsp;services.\u003c/li\u003e\n \u003cli\u003eTo\u0026nbsp;determine\u0026nbsp;the\u0026nbsp;financial\u0026nbsp;barriers\u0026nbsp;in\u0026nbsp;accessing\u0026nbsp;health\u0026nbsp;care\u0026nbsp;services.\u003c/li\u003e\n \u003cli\u003eTo assess the utilization of health care services.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"2.\t Literature Review","content":"\u003cp\u003eA study done by Owoaje et al. emphasized that access to health services is a fundamental right, yet numerous challenges and barriers can impede this access, particularly among migrant communities such as the Sudanese in various host countries. Understanding these challenges is crucial for improving health outcomes and ensuring equitable healthcare provision. The study highlighted several barriers faced by migrant communities in accessing health services, including language barriers, cultural differences, and lack of familiarity with the healthcare system [15].\u003c/p\u003e\n\n\n\u003cp\u003eA study done by Blessing Kanengoni-Nyatara, Kathleen B., Carolina, Nadia A., and Charles investigated access to healthcare for migrants and refugees in Aotearoa, New Zealand. The studies discovered that migrants and refugees face challenges in receiving healthcare due to a number of overlapping variables. Three primary issues were identified: attitudinal barriers, structural barriers, and the need for recommendations to increase access to healthcare in different situations. Most studies reported a lack of sensitivity among medical professionals to the cultural backgrounds of migrant and refugee patients, as well as discrimination by healthcare providers. Participants from migrant, refugee, and refugee-like backgrounds shared experiences of rejection in both primary and secondary healthcare settings [16].\u003c/p\u003e\n\n\n\u003cp\u003eA follow-up study by Blessing Kanengoni-Nyatara, Kathleen B., Carolina, Nadia A., and Charles in 2024 investigated access to healthcare for migrants and refugees in Aotearoa, New Zealand. The dominant issue across most studies was language barriers and their consequences in exploring, collecting, and using healthcare services for migrants and refugees. As stated by Jayan and Dutta, multiple organizations lacked access to easily translated material on COVID-19 or support services, aggravating the problem [16].\u003c/p\u003e\n\n\n\u003cp\u003eA study conducted by Judith, Isabella, and Bernhard in 2019 compared health outcomes between Austrians and refugees. Findings from the Refugee Health and Integration Survey (ReHIS) showed that one in three women assessed their health as \u0026ldquo;very good,\u0026rdquo; while 18% rated it as \u0026ldquo;not good.\u0026rdquo; Among men, 42% rated their health as \u0026ldquo;very good,\u0026rdquo; and 14% as \u0026ldquo;not good.\u0026rdquo; Self-rated health (SRH) results suggested that the increased use of hospital emergency treatments was partly due to a lack of information about available general practitioners and specialists. Accessibility issues were also noted, with refugees consulting dentists far less frequently than Austrians. This demonstrates that, despite the high demand for treatment, migrants face limited access to information. \u003c/p\u003e\n\u003cp\u003eThey also experience greater difficulties arranging appointments and paying for treatments. Specialty services such as dental care and physiotherapy often require co-payments, creating hidden cost burdens that discourage preventive and primary care. \u003c/p\u003e\n\u003cp\u003eOverall, the study emphasized that knowledge of and access to primary healthcare professionals should be improved to reduce reliance on emergency departments, which would also reduce costs. Providing trained interpreters, including online translators, can help overcome language barriers. The authors further advocated for implementing policies to promote refugee integration into the healthcare system at all levels, addressing both language and socio-cultural challenges. The study also found that nine in ten men and all women surveyed in ReHIS had consulted a healthcare provider (physician or specialist) in 2018, but specialists were less often consulted by refugees compared to Austrians [17].\u003c/p\u003e\n\n\u003cp\u003eA study conducted by Zaid, Eyup, and Gurel in 2018 investigated Syrian refugees in Turkey. Participants reported financial challenges that limited business growth, including restricted access to banking, rigid bank procedures, high tax rates, limited capital mobility, and inadequate facilities [18].\u003c/p\u003e\n\n\n\u003cp\u003eA study conducted by Kuan Ai Seon, Chen Tzeng-Ji, and Lee Wui-Chiang in 2017 in Taiwan showed that the vast majority of migrants in Taiwan (91.9%) were covered by the country\u0026rsquo;s universal National Health Insurance (NHI). At the time, there were approximately 720,000 international migrants (54.5% women). Study participants reported three main barriers to healthcare in Taiwan: language and information, sociocultural and economic factors, and policy and resource limitations [19].\u003c/p\u003e\n\n\n\u003cp\u003eA study conducted by Ana P., Ifna, Xiao, Sylvia, and F\u0026eacute;lice in 2018 used cross-sectional survey data in Tijuana, Mexico, to investigate access to health services among Mexican immigrants and migrants to the U.S. across migration phases, including pre-departure, destination, interception, and return. The findings indicated that immigrants\u0026rsquo; access to healthcare decreased after the pre-departure phase. This was demonstrated by significantly reduced opportunities to obtain healthcare and secure a regular source of care, as well as higher odds of reporting foregone care during the destination, interception, and return phases compared to the pre-departure phase [20].\u003c/p\u003e\n\n\n\u003cp\u003eA 2018 study by Katongole S.P., Namaganda S., Baryamureeba B., et al. in Uganda investigated barriers to healthcare access for refugees in settlements using a mixed-methods approach that included surveys and interviews with both refugees and healthcare providers. The study found that 62% of refugees encountered challenges in accessing healthcare due to long wait times and insufficient medical supplies (p \u0026lt; 0.01). Additionally, 55% cited transportation issues, such as the lack of affordable options, as a major obstacle to reaching healthcare facilities (p \u0026lt; 0.01). Furthermore, 50% of refugees had limited awareness of available health services, leading to delays in seeking care (p \u0026lt; 0.05) [21].\u003c/p\u003e"},{"header":"3.\t METHODOLOGY","content":"\u003ch2\u003e3.1 Study Design:\u003c/h2\u003e\n\u003cp\u003eA cross-sectional community-based study.\u003c/p\u003e\n\u003ch2\u003e3.2 Study Area:\u003c/h2\u003e\n\u003cp\u003eThe\u0026nbsp;study\u0026nbsp;was\u0026nbsp;conducted\u0026nbsp;within\u0026nbsp;the\u0026nbsp;Sudanese\u0026nbsp;community\u0026nbsp;in\u0026nbsp;Kigali,\u0026nbsp;the\u0026nbsp;capital\u0026nbsp;city\u0026nbsp;of\u0026nbsp;Rwanda, located in East Africa, Rwanda is known for its post-genocide rehab and development efforts during the last few decades. Rwanda, nicknamed the \u0026quot;Land of a Thousand Hills,\u0026quot; is\u0026nbsp;famous for its conservation efforts and unusual recovery from the 1994 genocide. Despite these advancements, barriers to healthcare access remain, particularly for immigrant communities such as the Sudanese.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp;3.3. Study population:\u003c/h2\u003e\n\u003cp\u003eThe study population included Sudanese individuals in Rwanda, specifically those aged 18 years and older, from various backgrounds and reasons for settling in Rwanda. There was no accurate\u0026nbsp;statistic\u0026nbsp;of\u0026nbsp;the\u0026nbsp;number\u0026nbsp;of\u0026nbsp;Sudanese\u0026nbsp;in\u0026nbsp;Rwanda\u0026nbsp;at\u0026nbsp;the\u0026nbsp;time\u0026nbsp;of\u0026nbsp;the\u0026nbsp;data\u0026nbsp;collection\u0026nbsp;so\u0026nbsp;the exact size of population was unknown.\u003c/p\u003e\n\u003ch2\u003e3.4 Sampling:\u003c/h2\u003e\n\u003ch2\u003e3.4.1 \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSampling technique:\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eConvenience sampling technique was used, where participants were selected based on their availability and willingness to participate through internet access. This technique was chosen because access to the study population was limited, and the resources for sampling were constrained.\u003c/p\u003e\n\u003ch2\u003e3.4.2 \u0026nbsp;Sample size:\u003c/h2\u003e\n\u003cp\u003eThe sample size was determined by the number of Sudanese people in Rwanda. One hundred and two (102) participated who were able to respond to the online survey.\u003c/p\u003e\n\u003ch2\u003e3.3.1 Inclusion criteria:\u003c/h2\u003e\n\u003cp\u003eSudanese\u0026nbsp;Individuals\u0026nbsp;whose\u0026nbsp;nationality\u0026nbsp;based\u0026nbsp;on Sudanese\u0026nbsp;origin\u003c/p\u003e\n\u003cp\u003eSudanese\u0026nbsp;people who\u0026nbsp;are\u0026nbsp;currently\u0026nbsp;living\u0026nbsp;in\u0026nbsp;Rwanda,\u0026nbsp;regardless\u0026nbsp;of\u0026nbsp;their\u0026nbsp;legal\u0026nbsp;status\u003c/p\u003e\n\u003cp\u003eInclude the ages between 18 years and above.\u003c/p\u003e\n\u003ch2\u003e3.3.2 Exclusion criteria:\u003c/h2\u003e\n\u003cp\u003eNon-Sudanese\u0026nbsp;Individual\u003cstrong\u003es.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSudanese\u0026nbsp;individuals\u0026nbsp;under\u0026nbsp;18\u0026nbsp;years old.\u003c/p\u003e\n\u003cp\u003eSudanese\u0026nbsp;Individuals participated\u0026nbsp;from\u0026nbsp;Outside\u0026nbsp;of\u0026nbsp;Rwanda.\u003c/p\u003e\n\u003cp\u003eIndividuals who are unable to communicate effectively or not understand Arabic\u0026nbsp;and English Questionnaire\u003c/p\u003e\n\u003cp\u003eParticipants who were unwilling to participate.\u003c/p\u003e\n\u003ch2\u003e3.5 Data Collection tool:\u003c/h2\u003e\n\u003cp\u003eData\u0026nbsp;was\u0026nbsp;collected\u0026nbsp;using\u0026nbsp;an\u0026nbsp;online\u0026nbsp;questionnaire\u0026nbsp;shared\u0026nbsp;by\u0026nbsp;WhatsApp\u0026nbsp;taken\u0026nbsp;from\u0026nbsp;previous research [17,19 ,20] and the questionnaire was formulated to fit the research objectives. The questionnaire\u0026nbsp;was\u0026nbsp;written\u0026nbsp;in\u0026nbsp;English\u0026nbsp;then\u0026nbsp;translated\u0026nbsp;to\u0026nbsp;Arabic.\u0026nbsp;The\u0026nbsp;questionnaire\u0026nbsp;assessed\u0026nbsp;of\u0026nbsp;the following domains:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003esociodemographic profile\u003c/li\u003e\n \u003cli\u003eImmigration characteristics.\u003c/li\u003e\n \u003cli\u003eAccess to Health Services.\u003c/li\u003e\n \u003cli\u003eUtilization of Health Services.\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch2\u003e3.6 Data Management and Analysis:\u003c/h2\u003e\n\u003cp\u003eData was entered and analyzed to Microsoft Excel sheet and protected with password.\u0026nbsp;Analysis done for data of 102 participants, Analysis done on the statistical package for social sciences (SPSS) version 25. P value of 0.05 will be used as cutoff point of statistical significance for independent-sample\u0026nbsp;t-test\u0026nbsp;and\u0026nbsp;associations\u0026nbsp;between\u0026nbsp;two\u0026nbsp;categorical\u0026nbsp;variables\u0026nbsp;were assessed using the chi-square test. To describe our study population, we used frequency tables, bar charts, pie charts, graphs, percentage, means, and standard deviation.\u003c/p\u003e\n\u003ch2\u003e3.7 Ethical Considerations:\u003c/h2\u003e\n\u003cp\u003ePermission and approval were obtained from the research technical and ethical committee at the Faculty of Medicine, University of Medical Sciences and Technology. All the data were kept in a private folder, and weren\u0026rsquo;t spread or used in any other purpose. Research purposes and objectives were explained to participants in clear simple words and verbal consent was obtained from each participant. They were also notified about their rights to withdraw at any time without any deprivation.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"4\t RESULTS","content":"\u003ch2\u003e4.1 \u0026nbsp;Socio-Demographic Data:\u003c/h2\u003e\n\u003cp\u003eTable 4.1: shows the socio-demographic data among the participants (N = 102).\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1758617270.png\" width=\"717\" height=\"738\"\u003e\u003c/p\u003e\n\u003cp\u003eOut of 102 participants in this study, the majority were females {54.9%} aged from 18 to 26 years old {94.8%} and they were single {98%}. Moreover, most of the participants were at university level {93.1%}. Finally, most of the participants were in Rwanda for less than one year and {55.9%} had residency.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;4.1.1 Language:\u003c/p\u003e\n\u003cp\u003eThis study found that all the participants could speak Arabic {100%} and most of them could speak English {97%} while a few could speak French or Kinyarwanda {4.9%}.\u003c/p\u003e\n\u003cp\u003e4.1.2. Insurance Assessment:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;4.2:\u0026nbsp;shows\u0026nbsp;the\u0026nbsp;insurance assessment\u0026nbsp;among\u0026nbsp;the\u0026nbsp;participants\u0026nbsp;(N = 102)\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1758617381.png\" width=\"909\" height=\"459\"\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, only {16.7%} had a medical insurance and {11.8%} were private insurance.\u003c/p\u003e\n\u003ch2\u003e4.2 Access to Health services:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eTable\u0026nbsp;4.3:\u0026nbsp;shows\u0026nbsp;the\u0026nbsp;assessment\u0026nbsp;of\u0026nbsp;health\u0026nbsp;services\u0026nbsp;access\u0026nbsp;among\u0026nbsp;the\u0026nbsp;participants\u0026nbsp;(N\u0026nbsp;= 102)\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1758617430.png\" width=\"612\" height=\"894\"\u003e\u003c/p\u003e\n\u003cp\u003eMost of the participants rated their health as very good {34.3%}, they were aware of the available health services in Rwanda {65.7%} and {54.9%} went to get these healthcare services in Rwanda. Moreover, most of the participants were naturally satisfied with these services {53.7%} and {46.1%} were naturally communicating\u003c/p\u003e\n\u003ch2\u003e4.2.1 \u0026nbsp;Healthcare services in Rwanda:\u003c/h2\u003e\n\u003cp\u003eMost of the participants in this study chose hospital {30.4%} and PHC {21.6%} as their destination to access health services.\u003c/p\u003e\n\u003ch2\u003e4.3 Difficulties:\u003c/h2\u003e\n\u003cp\u003eThis study found that the most common difficulties that faced the participants in accessing health services were long waiting time {24.8%}, high cost of the services {23.8%}, language barriers {21.7%} and transportation {20.8%}.\u003c/p\u003e\n\u003ch2\u003e4.4Utilization of Health Services:\u003c/h2\u003e\n\u003cp\u003eTable\u0026nbsp;4.4:\u0026nbsp;shows\u0026nbsp;the\u0026nbsp;utilization of\u0026nbsp;health\u0026nbsp;services\u0026nbsp;among the\u0026nbsp;participants\u0026nbsp;(N\u0026nbsp;= 102)\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1758617534.png\" width=\"773\" height=\"804\"\u003e\u003c/p\u003e\n\u003cp\u003eConcerning\u0026nbsp;utilization\u0026nbsp;of\u0026nbsp;health\u0026nbsp;services,\u0026nbsp;most\u0026nbsp;of\u0026nbsp;the\u0026nbsp;participants\u0026nbsp;went\u0026nbsp;to\u0026nbsp;these\u0026nbsp;facilities\u0026nbsp;one to two times per year {38.2%} and the majority went to PHC facilities {33.3%}. Moreover, {42.2%} of the participants did delay their seeking healthcare services in Rwanda and {51%} were dissatisfied with the quality of healthcare services received in Rwanda.\u003c/p\u003e\n\u003ch2\u003e4.4.1 Primary Reasons for Visiting Healthcare Facilities:\u003c/h2\u003e\n\u003cp\u003eThis study found that illness / injury was the commonest reason for visiting health facilities among the participants {45%} followed by routine checkups {24.5%}.\u003c/p\u003e\n\u003ch2\u003e4.5 Associations:\u003c/h2\u003e\n\u003cp\u003eTable 4.5: shows the association between access to health and influencing factors among the participants (N = 102).\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1758617617.png\" width=\"885\" height=\"905\"\u003e\u003c/p\u003e\n\u003cp\u003eIn this study the only significant association was between access to health and transportation, P value \u0026lt; 0.05 {0.023}\u003c/p\u003e"},{"header":"5 DISCUSSION","content":"\u003cp\u003eHealthcare services are a fundamental human right for maintaining public health, both for native and foreign residents of a country. Foreigners in different countries face various challenges regardless of the reasons for settling. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study examined healthcare access among Sudanese people in Rwanda and explored the challenges and barriers they face.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted on Sudanese people living in Rwanda, with a sample size of 102 participants in 2024, with the following significant findings:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the sociodemographic data, most participants were aged between 18\u0026ndash;26 years, and the majority were female. More than two-thirds of participants had been residing in Rwanda for less than one year. This may explain why many participants were unaware of available health services, as they had only recently settled in Rwanda.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith respect to healthcare services, hospital services (inpatient and outpatient) and primary healthcare services were the most commonly accessed by participants. This finding aligns with the study conducted by Kuan, Ai Seon; Chen, Tzeng-Ji; and Lee, Wui-Chiang, which reported that about one-third of ReHIS respondents received hospital treatment during the last 12 months, with hospital daycare being more frequent [19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the participants, 34.3% assessed their health as \u0026ldquo;very good,\u0026rdquo; while 65.7% were aware of the availability of health services. The increased reliance on hospital emergency services may be partly due to a lack of information about available general practitioners and specialists. This finding is consistent with the study by Kanengoni-Nyatara, B., Watson, K., Galindo, C., et al. [16].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLong waiting times were identified by 84.7% of participants as the most critical structural barrier to accessing healthcare. This indicates a systemic problem within the healthcare system that disproportionately impacts migrant populations. These findings are consistent with the study conducted by Owoaje et al. [15], which highlighted similar structural barriers in host countries, where migrants frequently endure extended waiting times, often worsened by their non-national status. Similarly, this reflects the experience of the Sudanese community, who encounter delays in accessing care.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Language was identified as another major barrier, with 83.7% of participants citing it as a significant challenge. Only 4.9% of participants were able to speak French or Kinyarwanda, highlighting a serious communication gap that hinders effective access to healthcare. This result aligns with the study by Kanengoni-Nyatara et al. in Aotearoa [16], which identified language as the most significant barrier to healthcare access for migrants and refugees. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLikewise, the study conducted in Taiwan by Kuan Ai Seon et al. [19] emphasized how limited language proficiency obstructs healthcare access, often leading to misunderstandings and lower quality of care. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe lack of interpreters or bilingual healthcare providers further exacerbates the issue, making it difficult for the Sudanese community to navigate the healthcare system, understand medical advice, and express health concerns. These findings are consistent with global trends, where language barriers are a common obstacle to quality healthcare for migrant communities.\u003c/p\u003e\n\u003cp\u003eFinancial barriers were also prominent, with 69.1% of participants citing the high cost of healthcare as a major challenge. Additionally, only 15% of participants had health insurance, limiting their access to affordable services. This is in agreement with the study by Kuan Ai Seon et al. [19], which reported that high costs were a major barrier to healthcare access among migrants in Taiwan. Low health insurance coverage forces many migrants to pay out-of-pocket, discouraging them from seeking care and leading to delayed or missed treatments. These findings reinforce global evidence that financial challenges represent a substantial barrier to healthcare access among migrants.\u003c/p\u003e\n\u003cp\u003eThe study also identified a significant association between access to healthcare and transportation, with a p-value of 0.023, indicating that transportation plays a crucial role in determining healthcare accessibility for the Sudanese community in Rwanda. Difficulties in accessing reliable and affordable transportation can hinder medical care, leading to missed appointments, delayed treatment, and reduced utilization of healthcare services. This finding is consistent with the study conducted by Katongole S.P., Namaganda S., Baryamureeba B., et al. [21], in which 55% of refugees identified transportation issues\u0026mdash;particularly the lack of affordable options\u0026mdash;as a major barrier to accessing healthcare facilities (p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eLimitations:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are several limitations to consider in this study. The sample was not distributed equally among the Sudanese community and may not represent the studied populations in Rwanda, which might affect outcomes of the current study.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003ecommunity-based\u0026nbsp;health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 278px;\"\u003e\n \u003cp\u003e(CBHI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003euniversal\u0026nbsp;health\u0026nbsp;coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 278px;\"\u003e\n \u003cp\u003e(UHC)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eRefugee\u0026nbsp;Health\u0026nbsp;and Integration Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 278px;\"\u003e\n \u003cp\u003e(ReHIS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eself-rated health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 278px;\"\u003e\n \u003cp\u003e(SRH)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eNational\u0026nbsp;Health Insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 278px;\"\u003e\n \u003cp\u003e(NHI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDedications\u003c/h2\u003e\n\u003cp\u003eThis research is dedicated to my father, my first and last supporter\u0026mdash;may Allah have mercy on him; my mother, the strongest woman and the source of my strength in this life; to Mohammed and Arwa, my role models who have always been supportive, helpful, and present for me; to my cousin Asma, who took care of me all the time; thank you to my uncle, Ahmed, Mahmood, and Salwa, and all my uncles and aunts; and to my friends, Areej, Rahaf ,Manhal, Aseel, Shahad, Mawada, Istifaa ,Fajr, Nihad and Tayseer. Full acknowledge from the deepest part of my heart for unlimited support and being nice partners in this journey and make it easier for me.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgment:\u003c/h2\u003e\n\u003cp\u003eI\u0026nbsp;would\u0026nbsp;like\u0026nbsp;to\u0026nbsp;thank\u0026nbsp;my\u0026nbsp;supervisor\u0026nbsp;Dr.\u0026nbsp;Babiker\u0026nbsp;Mohammed\u0026nbsp;Ali\u0026nbsp;from\u0026nbsp;the\u0026nbsp;bottom\u0026nbsp;of\u0026nbsp;my\u0026nbsp;heart, for his contribution to this research, and for my co-supervisor Abeer Ahmed for her guidance and helping me, I would like to thank my dearest uncle Dr. Ahmed Mohammed Ali, Ammar Srar, D.r Moez for their efforts with me and Dr. Ahmed Abdulrahman for everything.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization. Universal health coverage (UHC) [Internet]. 2020 [cited 2024 Aug 8]. Available from: https://www.who.int/news-room/fact-sheets/detail/universal- health-coverage-(uhc)\u003c/li\u003e\n \u003cli\u003eMarmot M. The health gap: the challenge of an unequal world. The Lancet. 2015;386(10011):2442-4.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Human rights and health [Internet]. 2017 [cited 2024 Aug 8]. Available from: https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health\u003c/li\u003e\n \u003cli\u003eMinistry of Health Rwanda. Health sector policy. Kigali: Ministry of Health; 2020.\u003c/li\u003e\n \u003cli\u003eUNHCR Rwanda. Sudanese refugees in Rwanda [Internet]. 2023 [cited 2024 Aug 8]. Available from: https://www.unhcr.org/rw/sudanese-refugees .\u003c/li\u003e\n \u003cli\u003eInternational Organization for Migration. Migration in Rwanda: a country profile 2021. Kigali: IOM; 2021.\u003c/li\u003e\n \u003cli\u003eWang H, Tesfaye R, Ramana GN, Chekagn CT. Ethiopia health extension program: an institutionalized community approach for universal health coverage. Washington, DC: World Bank; 2016.\u003c/li\u003e\n \u003cli\u003eSudhinaraset M, Ingram M, Lofthouse HK, Montoya M. The influence of social and cultural factors on health care-seeking behavior in a marginalized community: perspectives of community health workers. J Community Health. 2016;41(4):784-91.\u003c/li\u003e\n \u003cli\u003eJacobs B, Ir P, Bigdeli M, Annear PL, Van Damme W. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan. 2012;27(4):288-300.\u003c/li\u003e\n \u003cli\u003ePeters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and access to health care in developing countries. Ann N Y Acad Sci. 2008;1136(1):161-71.\u003c/li\u003e\n \u003cli\u003eLaban CJ, Gernaat HB, Komproe IH, Schreuders BA, De Jong JT. Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. J Nerv Ment Dis. 2004;192(12):843-51.\u003c/li\u003e\n \u003cli\u003eNational Institute of Statistics of Rwanda. Rwanda demographic and health survey 2020. Kigali: NISR; 2020.\u003c/li\u003e\n \u003cli\u003eChemouni B. The political path to universal health coverage: power, ideas and community- based health insurance in Rwanda. World Dev. 2018; 106:87-98.\u003c/li\u003e\n \u003cli\u003eFarmer PE, Nutt CT, Wagner CM, Sekabaraga C, Nuthulaganti T, Weigel JL, et al. Reduced premature mortality in Rwanda: lessons from success. BMJ. 2013;346\u003c/li\u003e\n \u003cli\u003eThe right to health [Internet]. www.who.int. Available from: https://www.who.int/tools/your-life-your-health/know-your-rights/the-right-to-health\u003c/li\u003e\n \u003cli\u003eKanengoni-Nyatara, B., Watson, K., Galindo, C. \u003cem\u003eet al.\u0026nbsp;\u003c/em\u003eBarriers to and Recommendations for Equitable Access to Healthcare for Migrants and Refugees in Aotearoa, New Zealand: An Integrative Review. \u003cem\u003eJ Immigrant Minority Health\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e26\u003c/strong\u003e, 164\u0026ndash;180 (2024). https://doi.org/10.1007/s10903-023-01528-8\u003c/li\u003e\n \u003cli\u003eKohlenberger, Judith, et al. \u0026ldquo;Barriers to Health Care Access and Service Utilization of Refugees in Austria: Evidence from a Cross-Sectional Survey.\u0026rdquo; \u003cem\u003eHealth Policy\u003c/em\u003e, vol. 123, no. 9, Sept. 2019, pp. 833\u0026ndash;839, www.sciencedirect.com/science/article/pii/S0168851018305335, https://doi.org/10.1016/j.healthpol.2019.01.014.\u003c/li\u003e\n \u003cli\u003eAlrawadieh, Zaid, et al. \u0026ldquo;Understanding the Challenges of Refugee Entrepreneurship in Tourism and Hospitality.\u0026rdquo; \u003cem\u003eThe Service Industries Journal\u003c/em\u003e, vol.\u003c/li\u003e\n \u003cli\u003eKuan, Ai Seona,b; Chen, Tzeng-Jic,d,e; Lee, Wui-Chiange,f,*. Barriers to health care services in migrants and potential strategies to improve accessibility: A qualitative analysis. Journal of the Chinese Medical Association 83(1): p 95-101, January 2020. | DOI: 10.1097/JCMA.0000000000000224\u003c/li\u003e\n \u003cli\u003eMartinez-Donate, Ana P., et al. \u0026ldquo;Access to Health Care among Mexican Migrants and Immigrants: A Comparison across Migration Phases.\u0026rdquo; \u003cem\u003eJournal of Health Care for the Poor and Underserved\u003c/em\u003e, vol. 28, no. 4, 2017, pp. 1314\u0026ndash;1326, https://doi.org/10.1353/hpu.2017.0116.\u003c/li\u003e\n \u003cli\u003eKatongole SP, Namaganda S, Baryamureeba B, et al. Barriers to healthcare access among refugees in Uganda. BMC Health Services Research. 2018;18(1): 508.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Medical Sciences and Technology","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sudanese community in Rwanda, health care services, challenges and barriers, language barriers, migrants","lastPublishedDoi":"10.21203/rs.3.rs-7664379/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7664379/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccess to healthcare and equity are fundamental human rights. Rwanda, located in East Africa, has made significant progress in healthcare, economic growth and development efforts over the past few decades, since the national reconciliation that occurred post-genocide fighting. However, some challenges persist.\u003c/p\u003e\n\u003cp\u003eThe Sudanese community in Rwanda, mainly composed of refugees and migrants who fled war and Sudan instability and they face unique struggles due to their status and integration into Rwandan society. Hence, this study aims to raise awareness towards the challenges and barriers to address these challenges and barriers to ease accessing the healthcare services in Rwanda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis descriptive community-based cross-sectional study was carried out on a sample of 103 participants, they were selected through convenience sampling technique. Participants were selected based on their availability and willingness to participate. Data collected through an online questionnaire and Google form used to spread the questionnaire. Data obtained analyzed using Statistical Package for the Social Sciences 25 (SPSS), then the results presented by tables and charts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe study recruited 102 Sudanese participants, majority (54.9%) were female and 45.1% male. Most participants were aged 18-26. Out of the 102 participants, only one (1) participant did not have legal permission to reside in Rwanda, and data of 102 participants analyzed. All participants were native Arabic speakers, with only 4.9% able to speak French and Kinyarwanda, the languages predominantly used in Rwanda. Language barriers were reported by 21.7% of participants, and 20.8% faced difficulties with transportation. The most reported difficulty was long waiting times to access healthcare services, followed by high service costs (23.8%). Additionally, 45% of participants visited healthcare facilities for illness or injury, while 24.5% visited for routine check-ups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe Sudanese community in Rwanda faced significant challenges in accessing healthcare services due to long waiting times, high service costs, and language barriers. These findings highlight the need to raise awareness and develop inclusive healthcare policies that address these specific needs. Identifying barriers for accessing healthcare is crucial for informing policy- makers to create or develop some programs that would offer culturally appropriate, patient-centered care for the refugee community. In addition, these findings underscore the necessity for an increased support for both refugees and healthcare providers to enhance language proficiency and cultural competency.\u003c/p\u003e","manuscriptTitle":"Challenges and Barriers in Accessing Health Services Among the Sudanese Community in Rwanda, 2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 10:21:34","doi":"10.21203/rs.3.rs-7664379/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a53022c6-6d37-41eb-91b6-5d3a4a9220b4","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55053081,"name":"Hospital Medicine"},{"id":55053082,"name":"Health Policy"},{"id":55053083,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2025-09-23T10:21:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 10:21:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7664379","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7664379","identity":"rs-7664379","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}