When knowledge is not enough: barriers to recommended cassava processing in resource-constrained Kwango, Democratic Republic of Congo.

Background: Despite interventions to provide knowledge and improve bitter cassava processing in the Democratic Republic of Congo (DRC), cassava processing is sub-optimal. Consumption of insufficiently processed bitter cassava is associated with konzo, a neurological paralytic disease. Objective: This study aimed to explore barriers to appropriate cassava processing carried out by women in one deep rural, economically deprived area of DRC. Methods: A qualitative design used focus group discussions (FGDs) and participant observation to collect data among purposively selected women aged 15-61 years in Kwango, DRC. Data were analyzed using thematic analysis. Results: 15 FGDs with 131 women and 12 observations of cassava processing were undertaken. Observations indicated women did not follow recommended cassava processing methods. Although women were knowledgeable about cassava processing, two main barriers emerged: access to water and lack of money. Accessing water from the river to process cassava was burdensome, and the cassava was at risk of being stolen by soaking it in the river; therefore, women shortened the processing time. Cassava was not only used as a staple food but also as a cash crop, which led to households shortening the processing time to reach the market quickly. Conclusion: Knowledge about the risks of insufficient cassava processing and about safe processing methods alone is insufficient to change practices in a context of severe resource constraints. When planning nutrition interventions, it is critical to view the intervention in light of the socio-economic context in which the intervention will take place to improve its outcomes.

A qualitative study to explore dietary knowledge, beliefs, and practices among pregnant women in a rural health zone in the Democratic Republic of Congo.

BACKGROUND: A nutritious and healthy diet during pregnancy is essential for the health of both mother and baby. Inadequate dietary intake during pregnancy contributes to maternal malnutrition and can have lifelong effects on the health of the child. Maternal malnutrition is common in many low-income countries, including the Democratic Republic of Congo (DRC). Kwango province, DRC, has a high prevalence of malnutrition among all population groups, including macro and micronutrient deficiencies among pregnant women. The study aimed to explore the dietary knowledge and practices of a pregnant woman in this area. METHODS: This study adopted a qualitative approach using in-depth interviews (IDIs) with pregnant women and key informants, and focus group discussions (FGDs) with fathers and grandmothers in the community, to explore women's knowledge and practice about diet during pregnancy. Data were collected between January and April 2018. IDIs were conducted with pregnant women who were recruited at antenatal clinics during their second and third trimesters. IDIs were undertaken with selected key informants, who were health workers providing care to pregnant women, and included doctors, nurses, nutritionists, and community health workers. All IDIs and FGDs were audio-recorded, transcribed verbatim, and translated to English. The triangulation method and thematic analyses were used. RESULTS: Overall, women showed good general knowledge about nutrition and the need for increased and varied foods during pregnancy, but little technical knowledge about nutrients and sources of nutrition. Healthcare facilities, media, NGOs, and family members were the main sources of nutritional information. However, women were unable to put this knowledge into practice, primarily due to poverty and poor access to a variety of foods. The Popokabaka community accessed food from farming, fishing, and the market, although purchasing food was frequently unaffordable. Cassava flour was the most common daily food. Food taboos, traditional practices, and late ANC attendance were identified as factors that influenced dietary practices. CONCLUSIONS: Various social, economic, and environmental factors within the local community influenced dietary practices among pregnant women in rural DRC. A comprehensive approach is required to improve nutrition, and address food insecurity, cultural practices and improve the health outcomes of both mother and child.

'I am not only beneficial to the community but to the entire country, I am trained as a researcher now': Developing health research skills in low-income countries.

ABSTRACTPartnerships between Higher Education Institutions in the global South and North have potential for building capacity in public health research in low-resource countries. We present experiences of partners involved in a North-South-South partnership between universities in Norway, the Democratic Republic of Congo (DRC) and South Africa. The partnership aimed to establish a postgraduate programme in nutritional epidemiology at the University of Kinshasa, DRC, and develop a cadre of researchers and academic leaders to provide locally generated health research to inform policy. In-depth interviews were conducted with 31 purposively selected stakeholders, facilitators, and students from partner institutions. All participants expressed positive experiences, indicating that the partnership provided excellent opportunities to network, enriched participants' learning and enhanced academic growth, with benefits at individual, institutional, and country levels. Participants suggested that maintaining a common vision was important for success, facilitated by joint planning of project activities, focussing strongly on building research and academic capacity at Kinshasa School of Public Health and addressing local nutrition problems. Important challenges highlighted for future partnerships included failures of co-facilitation and co-supervision, poor research dissemination and policy impact, and concerns about sustainability. Notwithstanding, North-South-South partnerships can address skills shortages in public health research with significant benefits to all partner institutions.

A North-South-South partnership in higher education to develop health research capacity in the Democratic Republic of the Congo: the challenge of finding a common language.

BACKGROUND: Globally, increasing numbers of higher education institutions (HEIs) in non-English-speaking countries have adopted English as a medium of instruction (EMI), because of the perception that this provides opportunities to attract high-calibre students and academic staff, and engage with the international research community. We report an evaluation of a North-South-South collaboration to develop health research capacity in the Democratic Republic of the Congo (DRC) by establishing a postgraduate programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), where EMI was adopted. We report experiences and perceptions of stakeholders, facilitators and students about using EMI. METHODS: In-depth qualitative interviews were conducted between October and December 2019 among convenience sampled stakeholders (8), facilitators (11) and students (12) involved in the programme from all three partner institutions (University of Kinshasa; University of KwaZulu-Natal, South Africa; University of Bergen, Norway). Interviews were conducted in participants' language of preference (English or French), audio-recorded, transcribed verbatim and translated into English when required. Analysis employed a thematic approach. RESULTS: Most participants viewed EMI positively, reporting that studying in English created opportunities to access relevant literature, improve interactions with the scientific community and advance their careers. As a result of adopting EMI, some students had opportunities to present research findings at international conferences and publish their research in English. English-speaking researchers from partner institutions were able to participate in supervision of students' research. However, inadequate English competency, particularly among students, was challenging, with some students reporting being unable to understand or interact in class, which negatively affected their academic performance. Further, EMI created barriers at KSPH among academic staff who were not proficient in English, leading to poor participation among non-English-speaking staff and lack of integration with other postgraduate programmes. Participants suggested additional English language support for EMI. CONCLUSION: Partnerships between HEIs could be a powerful tool to develop research capacity in low-income countries in line with United Nations Sustainable Development Goals. EMI could be a solution to language barriers faced by many such partnerships, but wide-ranging support to develop English proficiency among staff and students is essential to ensure that the challenges do not outweigh the benefits.

Establishing a postgraduate programme in nutritional epidemiology to strengthen resource capacity, academic leadership and research in the democratic republic of Congo.

BACKGROUND: Low- and Middle-income countries (LMIC) face considerable health and nutrition challenges, many of which can be addressed through strong academic leadership and robust research translated into evidence-based practice. A North-South-South partnership between three universities was established to implement a master's programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), Democratic Republic of Congo (DRC). The partnership aimed to develop academic leadership and research capacity in the field of nutrition in the DRC. In this article we describe the educational approach and processes used, and discuss successes, challenges, and lessons learned. METHODS: Self-administered questionnaires, which included both open and closed questions, were sent to all graduates and students on the master's programme to explore students' experiences and perceptions of all aspects of the educational programme. Quantitative data was analysed using frequencies, and a thematic approach was used to analyse responses to open-ended questions. RESULTS: A two-year master's programme in Nutritional Epidemiology was established in 2014, and 40 students had graduated by 2020. Key elements included using principles of authentic learning, deployment of students for an internship at a rural residential research site, and support of selected students with bursaries. Academic staff from all partner universities participated in teaching and research supervision. The curriculum and teaching approach were well received by most students, although a number of challenges were identified. Most students reported benefits from the rural internship experience but were challenged by the isolation of the rural site, and felt unsupported by their supervisors, undermining students' experiences and potentially the quality of the research. Financial barriers were also reported as challenges by students, even among those who received bursaries. CONCLUSION: The partnership was successful in establishing a Master Programme in Nutritional Epidemiology increasing the number of nutrition researchers in the DRC. This approach could be used in other LMIC settings to address health and nutrition challenges.

Translating new evidence into clinical practice: a quasi-experimental controlled before-after study evaluating the effect of a novel outreach mentoring approach on knowledge, attitudes and confidence of health workers providing HIV and infant feeding counselling in South Africa.

OBJECTIVES: We report the effectiveness of a mentoring approach to improve health workers' (HWs') knowledge, attitudes and confidence with counselling on HIV and infant feeding. DESIGN: Quasi-experimental controlled before-after study. SETTING: Randomly selected primary healthcare clinics (n=24 intervention, n=12 comparison); two districts, South Africa. PARTICIPANTS: All HWs providing infant feeding counselling in selected facilities were invited. INTERVENTIONS: Three 1-2 hours, on-site workshops over 3-6 weeks. PRIMARY OUTCOME MEASURES: Knowledge (22 binary questions), attitude (21 questions-5-point Likert Scale) and confidence (19 questions-3-point Likert Scale). Individual item responses were added within each of the attitude and confidence domains. The respective sums were taken to be the domain composite index and used as a dependent variable to evaluate intervention effect. Linear regression models were used to estimate the mean score difference between intervention and comparison groups postintervention, adjusting for the mean score difference between them at baseline. Analyses were adjusted for participant baseline characteristics and clustering at health facility level. RESULTS: In intervention and comparison sites, respectively: 289 and 131 baseline and 253 and 114 follow-up interviews were conducted (August-December 2017). At baseline there was no difference in mean number of correctly answered knowledge questions; this differed significantly at follow-up (15.2 in comparison; 17.2 in intervention sites (p<0.001)). At follow-up, the mean attitude and confidence scores towards breast feeding were better in intervention versus comparison sites (p<0.001 and p=0.05, respectively). Controlling for confounders, interactions between time and intervention group and preintervention values, the attitude score was 5.1 points significantly higher in intervention versus comparison groups. CONCLUSION: A participatory, low-intensity on-site mentoring approach to disseminating updated infant feeding guidelines improved HWs' knowledge, attitudes and confidence more than standard dissemination via a circular. Further research is required to evaluate the effectiveness, feasibility and sustainability of this approach at scale.

An educational intervention to update health workers about HIV and infant feeding.

Clinical guidelines are used to translate research findings into evidence-based clinical practice but are frequently not comprehensively adopted by health workers (HWs). HIV and infant feeding guidelines were revised by the World Health Organization to align feeding advice for HIV-exposed and unexposed infants, and these were adopted in South Africa in 2017. We describe an innovative, team-based, mentoring programme developed to update HWs on these guidelines. The intervention was underpinned by strong theoretical frameworks and aimed to improve HWs' attitudes, knowledge, confidence, and skills about breastfeeding in the context of HIV. On-site workshops and clinical mentoring used interactive participatory methods and a simple low-tech approach, guided by participants' self-reported knowledge gaps. Workshops were conducted at 24 participating clinics over three sessions, each lasting 1-2 hr. Evaluation data were collected using a self-administered questionnaire. Of 303 participating HWs, 249/303 (82.2%) attended all workshops. Achieving high workshop attendance was challenging and "catch-up" sessions were required to achieve good coverage. Common knowledge gaps identified included antiretroviral therapy adherence monitoring during breastfeeding and management of viral load results (173 participants), management of breast conditions (79), and advice about expressing and storing breastmilk (64). Most participants reported all their knowledge gaps were addressed and anticipated that their practice would change. We describe a feasible, sustainable approach to updating HWs on HIV and infant feeding guidelines and improving skills in breastfeeding counselling in resource-constrained settings. This approach could be adapted to other topics and, with further evaluation, implemented at scale using existing resources.