Community perceptions of a biopsychosocial model of integrated care in the health center: the case of 4 health districts in South Kivu, Democratic Republic of Congo.

BACKGROUND: Biopsychosocial care is one of the approaches recommended in the health system by the WHO. Although efforts are being made on the provider side to implement it and integrate it into the health system, the community dynamic also remains to be taken into account for its support. The objective of this study is to understand the community's perceptions of the concept of integrated health care management according to the biopsychosocial approach (BPS) at the Health Center of a Health District and its evaluation in its implementation. METHODS: This cross-sectional study was done in six Health Areas belonging to four Health Districts in South Kivu, DRC. We conducted 15 semi-directive individual interviews with 9 respondents selected by convenience, including 6 members of the Development Committees of the Health Areas, with whom we conducted 12 interviews and 3 patients met in the health centers. The adapted Normalization MeAsure Development (NoMAD) tool, derived from the Theory of the Normalization Process of Complex Interventions, allowed us to collect data from November 2017 to February 2018, and then from November 2018 to February 2019. After data extraction and synthesis, we conducted a thematic analysis using the NoMAD tool to build a thematic framework. Six themes were grouped into three categories. RESULTS: Initially, community reports that the BPS approach of integrated care in the Health Centre is understood differently by providers; but then, through collective coordination and integrated leadership within the health care team, the approach becomes clearer. The community encouraged some practices identified as catalysts to help the approach, notably the development of financial autonomy and mutual support, to the detriment of those identified as barriers. According to the community, the BPS model has further strengthened the performance of health workers and should be expanded and sustained. CONCLUSIONS: The results of our study show the importance of community dynamics in the care of biopsychosocial situations by providers. The barriers and catalysts to the mechanism, both community-based and professional, identified in our study should be considered in the process of integrating the biopsychosocial model of person-centered health care.

Is a bio-psychosocial approach model possible at the first level of health services in the Democratic Republic of Congo? An organizational analysis of six health centers in South Kivu.

BACKGROUND: The health system, in the Democratic Republic of Congo, is expected to move towards a more people-centered form of healthcare provision by implementing a biopsychosocial (BPS) approach. It's then important to examine how change is possible in providing healthcare at the first line of care. This study aims to analyze the organizational capacity of health centers to implement a BPS approach in the first line of care. METHODS: A mixed descriptive and analytical study was conducted from November 2017 to February 2018. Six health centers from four Health Zones (South Kivu, Democratic Republic of Congo) were selected for this study. An organizational analysis of six health centers based on 15 organizational capacities using the Context and Capabilities for Integrating Care (CCIC) as a theoretical framework was conducted. Data were collected through observation, document review, and individual interviews with key stakeholders. The annual utilization rate of curative services was analyzed using trends for the six health centers. The organizational analysis presented three categories (Basic Structures, People and values, and Key Processes). RESULT: This research describes three components in the organization of health services on a biopsychosocial model (Basic Structures, People and values, and Key processes). The current functioning of health centers in South Kivu shows strengths in the Basic Structures component. The health centers have physical characteristics and resources (financial, human) capable of operating health services. Weaknesses were noted in organizational governance through sharing of patient experience, valuing patient needs in Organizational/Network Culture, and Focus on Patient Centeredness & Engagement as well as partnering with other patient care channels. CONCLUSION: This study highlighted the predisposition of health centers to implement a BPS approach to their organizational capacities. The study highlights how national policies could regulate the organization of health services on the front line by relying more on the culture of teamwork in the care structures and focusing on the needs of the patients. Paying particular attention to the values of the agents and specific key processes could enable the implementation of the BPS approach at the health center level.

Violence against health care workers in a crisis context: a mixed cross-sectional study in Eastern Democratic Republic of Congo.

BACKGROUND: Health Care Workers (HCWs) in conflict zones face high levels of violence while also playing a crucial role in assisting the population in distress. For more than two decades, the eastern provinces of the Democratic Republic of the Congo (DRC), have been wracked by conflict. This study aims to describe the state of violence against HCWs and the potential prevention mechanisms in eastern DRC. METHODS: In North and South Kivu, between February 5 and 21, 2021, we conducted a mixed cross-sectional convergent study in health facilities (health centers and hospitals). An anonymized self-administered questionnaire was sent to HCWs about their experience of violence in the 12 months prior to the study. In-depth individual interviews with HCWs, present on the day of the investigation, were also done to explore their experience of violence. A descriptive analysis of the quantitative data and a thematic analysis of the qualitative data was carried out. RESULTS: Of a total of 590 participants, 276 (45.9%) reported having experienced violence in the 12 months before the study. In North Kivu, aggressors were more frequently the patients (43.7% vs. 26.5%) and armed group members (14.3% vs. 7.9%) than in South Kivu. Most respondents (93.5%) reported verbal aggression (insults, intimidation, death threats). Other forms of physical aggression including with bare hands (11.2%), firearm (1.81%), and stabbing (4.7%). Only nearly one-tenth of the attacks were officially reported, and among those reported a higher proportion of sanctions was observed in South Kivu (8.5%) than in North Kivu (2.4%). The mechanisms proposed to prevent violence against HCWs were community initiatives and actions to strength the health system. CONCLUSIONS: In Eastern DRC, HCWs face multiple and severe forms of aggression from a variety of individuals. The effects of such levels violence on HCWs and the communities they served could be devastating on the already pressured health system. Policy framework that defines the roles and responsibilities for the protection of HCWs and for the development and implementation of preparedness measures such as training on management of violence are possible solutions to this problem.

[Contrat unique, une approche innovante de financement du niveau intermédiaire du système de santé en République Démocratique du Congo : processus et défis de mise en œuvre].

Basket fund, an innovative approach for intermediate health system level financing in the Democratic Republic of Congo: Implementation process and challenges. BACKGROUND: Universal health coverage should allow countries to establish a financing strategy in order to guarantee the health of the population. AIM: Our objective was to describe the process and preliminary results of the implementation of the basket fund approach as a mode of financing the intermediate level (provincial health divisions) of the Congolese health system. SETTING: The study was conducted in the provincial health divisions (PHDs), representing the intermediate level of the health system in the Democratic Republic of Congo, where the basket fund approach has been implementedMethods: We conducted a mixed-methods convergent study as part of the evaluation of the basket fund approach in the Democratic Republic of Congo, five years after its introduction (2014-2019). Data was collected through a document review and individual interviews by telephone. A descriptive analysis of the quantitative data was conducted using Statistical Package for Social Sciences (SPSS) version 24 software. The qualitative data were analysed by thematic analysis using a pre-established thematic framework. RESULTS: The implementation of the basket fund approach was effective in some (PHDs) (53.8% in 2016). The operating costs of the PHDs varied according to the size, density and number of health zones covered. In the PHDs where the basket fund was operational, this approach appeared to contribute to improved planning and management in the use of resources, the partnership between technical and financial partners (TFPs and PHDs) and incentives for the performance of PHD agents. CONCLUSION: In the DRC, the basket fund approach has contributed to improved collaboration between donors in the health sector and facilitated the decentralisation of funding planning to the provincial level.

Factors associated with hospital outcomes of patients with penetrating craniocerebral injuries in armed conflict areas of the Democratic Republic of the Congo: a retrospective series.

INTRODUCTION: Penetrating craniocerebral injuries (PCCI) are types of open head injuries caused by sharp objects or missiles, resulting in communication between the cranial cavity and the external environment. This condition is deemed to be more prevalent in armed conflict regions where both civilians and military are frequently assaulted on the head, but paradoxically their hospital outcomes are under-reported. We aimed to identify factors associated with poor hospital outcomes of patients with PCCI. METHODS: This was a retrospective series of patients admitted at the Regional Hospital of Bukavu, DRC, from 2010 to 2020. We retrieved medical records of patients with PCCI operated in the surgical departments. A multivariate logistic regression model was performed to find associations between patients' admission clinico-radiological parameters and hospital outcomes. Poor outcome was defined as a Glasgow Outcomes Score below 4. RESULTS: The prevalence of PCCI was 9.1% (91/858 cases) among admitted TBI patients. More than one-third (36.2%) of patients were admitted with GCS < 13, and 40.6% of them were unstable hemodynamic. Hemiplegia was found in 23.1% on admission. Eight patients had an intracerebral hemorrhage. Among the 69 operated patients, complications, mainly infectious, occurred in half (50.7%) of patients. Poor hospital outcomes were observed in 30.4% and associated with an admission GCS < 13, hemodynamic instability, intracerebral hemorrhage, and hemiplegia (p < 0.05). CONCLUSION: The hospital poor outcomes are observed when patients present with hemodynamic instability, an admission GCS < 13, intracerebral hemorrhage, and hemiplegia. There is a need for optimizing the initial care of patients with PCCI in armed conflict regions.

Barriers and facilitators in the implementation of bio-psychosocial care at the primary healthcare level in South Kivu, Democratic Republic of Congo.

BACKGROUND: In the Democratic Republic of Congo (DRC), healthcare services are still focused on disease control and mortality reduction in specific groups. The need to broaden the scope from biomedical criteria to bio-psychosocial (BPS) dimensions has been increasingly recognized. AIM: The objective of this study was to identify the barriers and facilitators to providing healthcare at the health centre (HC) level to enable BPS care. SETTINGS: This qualitative study was conducted in six HCs (two urban and four rural) in South-Kivu (eastern DRC) which were selected based on their accessibility and their level of primary healthcare organization. METHODS: Seven focus group discussions (FGDs) involving 29 healthcare workers were organized. A data synthesis matrix was created based on the Rainbow Model framework. We identified themes related to plausible barriers and facilitators for BPS approach. RESULTS: Our study reports barriers common to a majority of HCs: misunderstanding of BPS care by healthcare workers, home visits mainly used for disease control, solidarity initiatives not locally promoted, new resources and financial incentives expected, accountability summed up in specific indicators reporting. Availability of care teams and accessibility to patient information were reported as facilitators to change. CONCLUSION: This analysis highlighted major barriers that condition providers' mindset and healthcare provision at the primary care level in South-Kivu. Accessibility to the information regarding BPS status of individuals within the community, leadership of HC authorities, dynamics of HC teams and local social support initiatives should be considered in order to develop an effective BPS approach in this region.

[Réforme et performance de l'Inspection de la santé et de la Division de la santé au Sud-Kivu en République Démocratique du Congo].

Reform and Performance of the Provincial Health Inspectorate and the Provincial Division of Health of South Kivu in the Democratic Republic of Congo. BACKGROUND: The intermediate level incorporated both the Provincial Health Inspectorate (IPS) and the Provincial Health Division (DPS) of Health. The new constitution of 2006 gave impetus to decentralisation, which became effective in 2015. The reform introduced at the intermediate level clearly separated the IPS and the DPS. This article assesses the effect of this reform on the performance of IPS and DPS in South Kivu, Democratic Republic of Congo. METHODOLOGY: The study is evaluative before and after and covers the period from 2012 to 2017. It uses mixed methods: three techniques were used to collect data including observation, document review and individual interviews. The analysis of the quantitative data concerned the evolution of the indicators; that of qualitative data was carried out by themes from two theoretical models: the ministerial functional framework and the 'Strengths, Weaknesses, Opportunities and Threats' analysis framework (SWOT analysis). Scores were assigned to each managerial function according to their level of performance for better comparison. RESULTS: After the reform, a decline in the performance score of activities devolved to IPS is noted, mainly due to the low funding of activities. On the other hand, in the DPS, the evolution of the score is favorable, because of the strong support given to the reform at this level by the partners and the government. The alignment of partners to a single contract for funding DPS activities is observed. The weak financing of the health sector by the government remains a weak point, however, and the brain drain a threat to institutional sustainability. The introduction of the single financing contract constitutes an opportunity to improve the performance of the provincial management team. DISCUSSION AND CONCLUSION: The study shows the improvement in the performance of managerial functions of the DPS and the regression to the IPS. The low funding of IPS by the Congolese government could jeopardise the reform.

Long-term effects of severe acute malnutrition during childhood on adult cognitive, academic and behavioural development in African fragile countries: The Lwiro cohort study in Democratic Republic of the Congo.

INTRODUCTION: Little is known about the outcomes of subjects with a history of severe acute malnutrition (SAM). We therefore sought to explore the long-term effects of SAM during childhood on human capital in adulthood in terms of education, cognition, self-esteem and health-related disabilities in daily living. METHODOLOGY: We traced 524 adults (median age of 22) in the eastern Democratic Republic of the Congo, who were treated for SAM during childhood at Lwiro hospital between 1988 and 2007 (median age 41 months). We compared them with 407 community controls of comparable age and sex. Our outcomes of interest were education, cognitive function [assessed using the Mini Mental State Examination (MMSE) for literate participants, or its modified version created by Ertan et al. (MMSE-I) for uneducated participants], self-esteem (measured using the Rosenberg Self-Esteem Scale) and health-related social and functional disabilities measured using the World Health Organization Disability Assessment Schedule (WHODAS). For comparison, we used the Chi-squared test along with the Student's t-test for the proportions and means respectively. RESULTS: Compared with the community controls, malnutrition survivors had a lower probability of attaining a high level of education (p < 0.001), of reporting a high academic performance (p = 0.014) or of having high self-esteem (p = 0.003). In addition, malnutrition survivors had an overall mean score in the cognitive test that was lower compared with the community controls [25.6 compared with 27.8, p = 0.001 (MMSE) and 22.8 compared with 26.3, p < 0.001(MMSE-I)] and a lower proportion of subjects with a normal result in this test (78.0% compared with 90.1%, p < 0.001). Lastly, in terms of health-related disabilities, unlike the community controls, malnutrition survivors had less social disability (p = 0.034), but no difference was observed as regards activities of daily living (p = 0.322). CONCLUSION: SAM during childhood exposes survivors to low human capital as regards education, cognition and behaviour in adulthood. Policy-deciders seeking to promote economic growth and to address various psychological and medico-social disorders must take into consideration the fact that appropriate investment in child health as regards SAM is an essential means to achieve this.

Gestion adaptative des centres de santé dans un environnement changeant en République démocratique du Congo.

INTRODUCTION: For three decades, the Democratic Republic of the Congo has faced recurrent wars. These have caused a significant burden of morbidity and mortality. In this context, the Katana Health Zone experienced several events that could have hampered the functioning of its health centers, which nevertheless continued to operate.Purpose of research: This study aims to identify specific determinants that have enabled health centers to adapt to a changing context. This is a cross-sectional study using mixed data, carried out in the Mugeri, Ihimbi and Ciranga health centers during the period 1990-2017 for qualitative data and from 2013 to 2017 for the quantitative data. It is based on observation, documentary review and individual interviews with 55 informants. RESULTS: The main events identified are the recurring rebellions, the massive arrival of refugees, the arrival of humanitarian aid, the earthquakes and the instability of human resources. The supply of services and care has continued thanks to the adaptation mechanisms developed, including the development and application of new directives and standards and dynamic community participation. CONCLUSIONS: On the one hand, the study demonstrates the value of adapting the procedures for managing financial aid and the operation of a health center in the event of a change in context; the effectiveness of a more structured and regular collaboration between different actors and the appropriation of the activities of the health center by the community. On the other hand, the study identifies the limits of selective and ad hoc interventions, which do not favor the effective development of health centers.