Setting

This study was conducted in rural communities within the catchment areas of three district hospitals (DHs) in Rwanda’s Northern Province. In Rwanda, each DH typically serves a population of approximately 200,000 people [23]. The first study site was Ruli DH, where TIP-Global Health (TIP-GH) [24], an international NGO, has maintained a presence since 2012. The second and third sites, Nemba and Kinihira DHs, were selected as locations where TIP-GH had no prior engagement before this study. The health facilities (HFs) within these catchment areas varied by classification (faith-based or public), geographic accessibility (including mountainous terrain and roads prone to flooding), and proximity to essential infrastructure. The number of HF partners supporting maternal and child health services was also considered during site selection.

Design

We conducted a qualitative study using an Interpretive Description (ID) approach to examine how HCPs and HCRs perceive and experience hope within primary healthcare settings. To generate context-specific and practical insights, we used the ID approach to explore the individual, interpersonal, and systemic influences on hope to inform policymakers and practitioners. We used focus group discussions (FGDs) and key informant interviews (KIIs) as our primary data collection methods. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure transparency in reporting [25].

Sampling

We aligned our sample size with established guidance on qualitative sample sizes necessary to achieve saturation and information power [26]. We used purposive sampling to recruit study participants, including HCPs involved in maternal and child healthcare services and HCRs, specifically pregnant women (PW) and mothers of children under five (MCU5). Given that the primary objective of this study was to examine general influences on hope within a primary healthcare context, women with diagnosed mental health conditions or critical illnesses were excluded. This exclusion was intended to minimize the impact of clinical factors that could substantially bias participants’ responses. Prior research indicates that individuals experiencing severe physical illness or psychological disorders may conceptualize and articulate hope in ways that differ markedly from those in stable health [7,27].

Data collection tool

We conducted FGDs and KII using semi-structured, open-ended questions. To ensure that our data collection tools were meaningful and contextually appropriate, we drew on multiple theoretical frameworks, recognizing that hope is influenced by emotional, social, behavioral, and structural factors. This approach enabled us to capture the complexity and intersectionality of influences on hope among HCPs and HCRs. We began with the Kinyarwanda version of the Herth Hope Index (HHI-K) [28], a validated tool in Rwanda, to guide the structure and content of our interview and FGD guides. The HHI conceptualizes hope as multidimensional, comprising a sense of future and purpose (temporality), the belief that positive outcomes are possible (positive readiness), and the importance of relationships (interconnectedness).

For the HCP guide, we applied the Capability, Opportunity, Motivation–Behavior (COM-B) model [29] to examine factors that enable or hinder the delivery of hopeful and patient-centered care. The COM-B model considers how internal factors (e.g., knowledge, attitudes) and external factors (e.g., workplace environment, system-level supports) influence behavior, helping us frame questions to understand how HCPs enact hope-related practices in care delivery. For the HCR guide, we used the Health Belief Model (HBM) [30] to explore how individuals perceive health, what motivates them to seek care, and what fosters hope and engagement. The HBM informed questions on perceived risks, benefits of treatment, self-efficacy, and the social and emotional factors influencing care-seeking behaviors. Additionally, we applied the Socioecological Model (SEM) [31] to examine how individual experiences of hope are shaped by interpersonal relationships, community norms, and healthcare system structures, allowing us to consider contextual an environmental influences beyond individual-level factors.

We developed and refined all data collection tools through collaborative discussions within the research team. The final guides were translated into Kinyarwanda by a bilingual TIP-GH staff member.

Data collection procedures

We collected data after obtaining verbal and written informed consent from all participants. We conducted 28 FGDs with 144 HCRs and 81 HCPs. Additionally, we conducted 23 KIIs with four policymakers, five researchers, and 14 health facility (HF) managers. All FGDs were held in healthcare facilities, while KIIs took place in participants’ local offices. Data collection occurred between 5 October 2020 and 10 February 2021. All sessions were conducted in Kinyarwanda and were audio recorded. FGD sessions lasted an average of 90 minutes, while KII sessions averaged 50 minutes. During data collection, the research team held monthly meetings to review interviewer field experiences and assess data saturation. As remuneration, FGD participants received 5 kg of Aheza, a locally produced fortified porridge.

Data analysis

We conducted a thematic analysis guided by the definition of hope in three dimensions as indicated by the HHI-K and the SEM to explore both personal and contextual dimensions of hope. The HHI-K informed the coding of individual experiences by highlighting three dimensions of hope: future orientation, readiness for change and interconnectedness. The SEM complemented this by situating hope within broader social and structural contexts, allowing us to examine influences at the individual, interpersonal, community, and health system levels, and to understand how external conditions shaped participants’ ability to sustain hope.

We present emerging themes with attention to both shared and distinct experiences between HCPs and HCRs. Our thematic analysis followed seven steps to ensure rigor: (1) transcription; (2) familiarization through open reading; (3) coding; (4) developing a working analytical framework; (5) applying the framework; (6) charting data into a framework matrix; and (7) interpreting the data.

All audio recordings were transcribed verbatim in Kinyarwanda and translated into English by two independent transcribers to minimize bias. We randomly selected 28 transcripts for open reading and collaboratively developed an initial codebook with 20 codes through discussion among five researchers. This iterative process allowed us to refine and finalize the codebook. We uploaded all transcripts into Dedoose software (version 9.0.90) for systematic coding. Identified codes were organized into categories, which were further refined into themes and subthemes based on team discussions.

Ethical consideration

We obtained ethical approval for this study from the Rwanda National Ethics Committee on 15 September 2020 (IRB 00001497, approval No. 692/RNEC/2020). We informed participants about the study objectives, assured them of voluntary participation, and guaranteed anonymity. Consent forms were read aloud in Kinyarwanda, allowing participants to ask questions before providing written consent. To protect privacy and confidentiality, we used personal identifiers only for initial contact, after which each participant was assigned a unique number stored separately from the data. All documents were securely stored on a password-protected laptop accessible only to the research team. During analysis, presentation, and publication, we used only unique identifiers. To safeguard participants’ mental well-being, we designed questions to minimize the risk of distress and trained data collectors to provide referrals for support if participants expressed psychological distress during data collection.

Participation and participants’ characteristics

Of the 28 FGDs conducted, among HCPs (n = 81), 63% were female, while nearly all HCRs (n = 144) were female (99%). HCPs were generally older, with an average age range of 37 years compared to 29 years for HCRs. Most HCPs had higher education levels, notably advanced diplomas (51%), whereas the majority of HCRs had primary education (74%). Regarding marital status, most participants in both groups were legally married. Table 1 presents the demographic characteristics of HCPs and HCRs who participated in the study.

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Table 1. Demographic information for focus group participants.

https://doi.org/10.1371/journal.pgph.0005095.t001

Of the 23 individuals participated in the KII, 58% of them were male and most were aged between 31 and 50 years (89%). Participants were generally well-educated, with 42% holding a bachelor’s degree and 37% having attained a master’s degree or higher. Almost all participants (95%) reported being legally married. Table 2 summarizes the demographic characteristics of the KII participants.

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Table 2. Demographic information for Key Informant Interview participants.

https://doi.org/10.1371/journal.pgph.0005095.t002

Thematic analysis and factors influencing hope in healthcare settings

The analysis highlighted how personal, interpersonal, and system-level factors shape hope of HCPs and HCRs. For HCRs, individual and interpersonal factors acted as both facilitators and barriers to hope. For HCPs, these factors primarily facilitated hope, while systemic factors presented the main barriers. Four main themes emerged from the analysis. S1 and S2 Files provide detailed subthemes and definitions, organized under the three psychometric dimensions of hope, for themes related to HCPs and HCRs, respectively.

Theme 1: Relationships driven by HCPs influence the quality of care.

Theme 2: Perceptions of the health system are formed through direct encounters with care delivery.

Theme 3: Continuous learning, knowledge sharing, and religious beliefs are fundamental facets for readiness for change and future orientation.

Theme 4: Interplay of HCPs’ passion for their role, work environment, and resource availability in shaping quality of Care.

Theme 1: Relationships driven by HCPs influence the quality of care

Theme 2: Perceptions of the health system are formed through direct encounters with care delivery

Theme 3: Continuous learning, knowledge sharing and religious beliefs are fundamental facets for readiness for change and future orientation

Theme 4: Interplay of HCPs’ passion for their role, work environment, and resource availability in shaping quality of Care

Interconnectedness

Participants consistently emphasized that human connection is foundational to care. HCRs valued respectful engagement and open dialogue, explaining that they were more likely to follow health advice when they felt genuinely seen and heard by their HCPs. These findings are echoed in prior studies linking HCPs-HCRs communication to satisfaction [32], better health outcomes [33], and service quality [34].

HCPs, in turn, expressed a sense of duty to build these relationships. They recognized that trust and rapport helped with care adherence and reducing skepticism at the community level. As others have found, strong interpersonal relationships can reinforce continuity of care and adherence to treatment [35,36] and even support psychosocial healing [37].

Connections among HCPs were equally important. Respondents described how peer support, teamwork, and open communication among colleagues and with leadership promoted a safer and more encouraging work environment, needed for delivering consistent care. Previous work highlights that peer collaboration enhances quality [38], supports patient safety [39], and fosters positive safety culture when backed by leadership [40–42].

HCPs identified systemic factors as barriers to building connections with HCRs and colleagues, which in turn diminished their sense of hope. Work overload, limited staff, and strained supervision led to burnout and occasionally disrespectful behaviors. Some HCPs noted that seeing their role as a “calling” rather than just a job helped them stay grounded and committed, even in difficult settings. However, as shown in other contexts, unresolved interprofessional conflicts and poor morale can erode the very relationships that uphold care quality [43,44]. Leaders also shared that misinformation, time constraints, and staff shortages impaired opportunities for meaningful interactions with HCRs as factors that ripple through the quality of care [45,46].

Readiness for change

People’s willingness to engage with new information or change their behavior closely depended on how much they trusted the source and how clearly the message was communicated. HCRs described how clear health education sessions and respectful dialogue increased their openness to change. In contrast, when HCPs gave rushed or inconsistent explanations, HCRs became doubtful or resistant. These dynamics align with evidence showing that unclear communication undermines adherence [47], while accessible information helps people navigate systemic barriers [48].

Negative care experiences such as ineffective treatment eroded the willingness to accept change. As WHO and others have emphasized, the experience of care is as vital as its content [49]. Without a sense of being heard or respected, both trust and behavior change suffer [50,51].

Belief systems and religion were central to how change was processed. Many participants shared how faith helped them cope with uncertainty and guided decisions. However, in some cases, religious convictions created tension with health interventions, particularly around family planning, echoing findings from Zimbabwe and other Low and Middle-Income Countries (LMICs) [52–55].

Among HCPs, readiness for change was strengthened by regular communication, training, and participatory leadership. Many HCPs and leaders noted that inadequate explanation of new guidelines hampered adoption. Studies show that communication channels and clear training significantly influence the uptake of change [56,57]. Peer learning and on-the-job coaching were seen as effective in preparing HCPs to adopt new practices [55,58], while leaders saw their role as facilitators of change through consistent engagement and shared vision [59].

Future orientation

Hope for the future perceived as both personal and systemic influences, was shaped by past experiences. HCRs described feeling more optimistic and confident in the health system when they received effective care, were treated respectfully, or witnessed recovery of a loved one. These experiences deepened their belief in the health system’s potential. Similar findings have been reported in maternal care, where quality and responsiveness influence satisfaction and use of services [41,60,61].

Conversely, poor outcomes particularly unresolved illness or ineffective treatment, left lasting impressions. “Not getting healed” was a common phrase, underlining how failed care can diminish hope not only for the individual but for their family and community. Word-of-mouth was a powerful force in shaping future expectations about care, especially in rural or tightly connected communities [62].

For HCPs, their outlook was influenced by workplace dynamics. Feeling appreciated, having a clear organizational vision, and receiving feedback were cited as key motivators. Prior studies have shown that these factors can strengthen creative performance and psychological resilience [63,64].

On the other hand, high workloads, resource scarcity, and inadequate pay undermined morale. Many HCPs expressed that their salaries did not meet basic living needs, which led to stress and a sense of stagnation. These realities mirror well-documented challenges in LMIC health systems [65–67], where staff shortages and low compensation fuel turnover, dissatisfaction, and burnout [68,69]. As echoed in the WHO framework, material and emotional support are both essential for sustaining professional engagement [59].

The findings of this study resonate with key constructs from the COM-B model, the Health Belief Model (HBM), and the Social Ecological Model (SEM), each offering a complementary lens through which to understand the dynamics of hope in primary healthcare. For example, participants’ sense of interconnectedness was reported to be shaped by respectful HCP-HCR interactions and peer support, reflects the SEM’s emphasis on interpersonal and organizational levels of influence on behavior [31]. At the same time, the readiness for change expressed by both HCRs and HCPs aligns with the COM-B components, suggesting that behavior change is rooted in multi-level enablers [29]. In this research, those enablers were highlighted with capability (through knowledge and training), opportunity (via supportive leadership), and motivation (driven by trust and belief in care). The Health belief model (HBM) was also evident in how HCRs described their likelihood of engaging with services, based on perceived benefits such as respectful treatment and perceived barriers such as poor communication or religious concerns. Cues to action, such as witnessing a peer’s recovery or receiving clear education is another component of HBM that was described by HCRs. These frameworks collectively illuminate how hope is constructed not just through individual beliefs but also within social and systemic environments, reinforcing the need for people-centered care strategies that address behavioral, relational, and structural factors.

In the Sustainable Development Goal (SDG) era, advancing maternal and primary healthcare requires more than service expansion, it requires investing in the human experience of care [67]. Hope, as this study shows, is not an abstract ideal. It is built or broken through every interaction, policy, and system decision. Recognizing the relational, behavioral, and structural influences that shape hope can inform more responsive, resilient, and people-centered health systems.

Recommendations

Positive relationships between HCPs and HCRs must be prioritized in Rwanda’s primary healthcare facilities. This requires implementing practices that promote clinical best practices, patient-centered care, effective communication, and trust-building to deliver high-quality healthcare services. Recognizing the profound impact of personal beliefs and attitudes on hope, capability building and knowledge sharing on these factors are crucial. This enables the HCPs to address biases and prejudices that may affect the delivery or reception of quality maternal health services.

By investing in the development of positive relationships, awareness, and education, the primary health system in Rwanda can create a more hopeful and supportive environment for both HCPs and HCRs, ultimately leading to improved healthcare outcomes and experiences.

Regular monitoring, evaluation, and assessment of HCR’s experiences in health care are essential to gathering first-hand valuable insights on the effectiveness of healthcare quality. Additionally, regular monitoring of the support that HCPs receive from their leaders fosters a positive and productive work environment.

Given resource shortages in Rwanda, coordination and collaboration among all stakeholders involved in maternal health should prioritize resource availability and overall service quality. Interconnectedness, readiness for change, and future orientation are essential elements for delivering effective primary health care that achieves desired improvements in maternal and child health outcomes in Rwanda.