RESUMEN
Zero-dose children remain highly vulnerable to vaccine-preventable diseases and can sustain transmission even in highly vaccinated populations. The WHO Immunization Agenda 2030 has prioritised reaching out to these children. We assessed the spatial distribution of zero-dose children together with the associated risk factors in a provincial capital in the Democratic Republic of Congo. A cross sectional survey was conducted in the city of Kikwit between September 28 and October 14, 2022. Data were collected both at household and health area level. QGIS and SATscan were used to describe and identify hotspots among zero-dose children, and a mixed effect logistic regression model was used to identify risk factors. Overall, 1,863 children aged 12-23 months were enrolled. Kikwit city had a 16.3% zero-dose prevalence, with significant variation between and within health zones. Two hotspots were identified through geospatial analysis, each spanning multiple health areas. Multilevel analysis revealed significant clustering at health area level and found six associated risk factors. These include the absence of home visits by community health workers (aOR = 1.90), living more than a kilometre from a health centre (aOR = 1.95), the mother's lack of tetanus vaccination (aOR = 3.16), and inability to name a vaccine-preventable disease (aOR = 3.20). However, secondary (aOR = 0.56) or tertiary (aOR = 0.21) education of mothers/guardians and belonging to Bunda (aOR = 0.36) or Mbala (aOR = 0.52) ethnicity reduced the risk of zero-dose. We observed a high prevalence of zero-dose children with a heterogeneous spatial distribution of epidemiological importance. Due to sub-zonal diversity, a health zone approach to reduce zero-dose immunization appears very limited. Zero-dose prevalence was related to the community health workers' home visit, to the distance of residence to a health centre and to household-level factors. Geospatial results could help in targeting priority health areas and communities for vaccination.
RESUMEN
In the Democratic Republic of the Congo (DRC), the prevalence of mental health issues could be greater than in other low-income and middle-income countries because of major risk factors related to armed conflicts and poverty. Given that mental health is an essential component of health, it is surprising that no systematic evaluation of mental health in the DRC has yet been undertaken. This study aims to undertake the first systematic review of mental health literacy and service provision in the DRC, to bridge this gap and inform those who need to develop an evidence base. This could support policymakers in tackling the issues related to limited mental health systems and service provision in DRC. Following Cochrane and PRISMA guidelines, a systematic (Web of Science, Medline, Public Health, PsycINFO, and Google Scholar) search was conducted (January 2000 and August 2023). Combinations of key blocks of terms were used in the search such as DRC, war zone, mental health, post-traumatic stress disorder (PTSD), anxiety, depression, sexual violence, war trauma, resilience, mental health systems and service provision. We followed additional sources from reference lists of included studies. Screening was completed in two stages: title and abstract search, and full-text screening for relevance and quality. Overall, 50 studies were included in the review; the majority of studies (n = 31) were conducted in the Eastern region of the DRC, a region devastated by war and sexual violence. Different instruments were used to measure participants' mental health such as the Hopkins Symptoms Checklist (HSCL-25), The Harvard Trauma Questionnaire, Patient Health Questionnaire (PHQ-9); General Anxiety Disorder (GAD-7), and Positive and Negative Symptoms Scale (PANSS). Our study found that wartime sexual violence and extreme poverty are highly traumatic, and cause multiple, long-term mental health difficulties. We found that depression, anxiety, and PTSD were the most common problems in the DRC. Psychosocial interventions such as group therapy, family support, and socio-economic support were effective in reducing anxiety, depression, and PTSD symptoms. This systematic review calls attention to the need to support sexual violence survivors and many other Congolese people affected by traumatic events. This review also highlights the need for validating culturally appropriate measures, and the need for well-designed controlled intervention studies in low-income settings such as the DRC. Better public mental health systems and service provision could help to improve community cohesion, human resilience, and mental wellbeing. There is also an urgent need to address wider social issues such as poverty, stigma, and gender inequality in the DRC.