Effect of a Water, Sanitation, and Hygiene Program on Handwashing with a Cleansing Agent among Diarrhea Patients and Attendants in Healthcare Facilities in the Democratic Republic of the Congo: A Randomized Pilot of the PICHA7 Program.

Healthcare-acquired infections are a major problem in healthcare facility settings around the world. The Democratic Republic of the Congo (DRC) has over 2 million diarrhea patients hospitalized each year. These healthcare settings become high-risk environments for spreading diarrheal illnesses such as cholera. The objective of the Preventative Intervention for Cholera for 7 Days (PICHA7) program is to develop evidence-based water, sanitation, and hygiene (WASH) interventions to reduce cholera and other severe diarrheal diseases in the DRC. The study objective was to evaluate the effectiveness of PICHA7 program delivery in increasing handwashing with a cleansing agent at stool/vomit- and food-related events in a healthcare facility setting among diarrhea patients and patient attendants. A pilot of the PICHA7 program was conducted among 284 participants in 27 healthcare facilities from March 2020 to November 2021 in urban Bukavu in the South Kivu Province of the DRC. The standard arm received the standard message provided in the DRC to diarrhea patients on the use of oral rehydration solution and a basic WASH message at healthcare facility discharge. The PICHA7 arm received the PICHA7 WASH pictorial module delivered by a health promoter focused on handwashing with a cleansing agent at the bedside of the diarrhea patient in the healthcare facility and provision of a soapy water bottle (water and detergent powder). Within 24 h of intervention delivery, a three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhea patients and their attendants. Compared to the standard arm, there was significantly more handwashing with a cleansing agent at key events in the PICHA7 arm (40% vs. 15%) (odds ratio: 5.04; (95% confidence interval (CI): 2.01, 12.7)). These findings demonstrate that delivery of the PICHA7 WASH pictorial module and provision of a soapy water bottle to diarrhea patients and their attendants presents a promising approach to increase handwashing with a cleansing agent among this high-risk population in healthcare facilities in the eastern DRC.

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.

A Quantitative and Qualitative Program Evaluation of a Case-Area Targeted Intervention to Reduce Cholera in Eastern Democratic Republic of the Congo.

Individuals living near cholera patients have an increased risk of cholera infections. Case-area targeted interventions (CATIs) promoting improved water, sanitation, and hygiene (WASH) present a promising approach to reducing cholera for those residing near cholera cases. However, there is limited evidence on the effectiveness and implementation of this approach in increasing WASH behaviors. We conducted a mixed-methods program evaluation in rural and urban eastern Democratic Republic of the Congo. The quantitative component included household structured observations and spot checks in CATI and control areas to assess WASH conditions and behaviors. The qualitative component included semi-structured interviews with CATI recipients, non-recipients, and implementers to assess CATI implementation. A total of 399 participants were enrolled in the quantitative evaluation conducted within 1 month of CATI delivery. For the qualitative evaluation, 41 semi-structured interviews were conducted, 30 with individuals in CATI areas (recipients and non-recipients) and 11 with CATI implementers. Handwashing with soap was low among both CATI and control area participants (1% vs. 2%, p = 0.89). Significantly more CATI area households (75%) had chlorine tablets present compared to control area households (0%) (p < 0.0001); however, the percentage of households with stored water free chlorine concentrations > 0.2 mg/L was low for both CATI and control area households (11% vs. 6%, p = 0.45). Implementers reported an insufficient supply of soap for distribution to recipients and mistrust in the community of their activities. CATI recipients demonstrated low knowledge of the correct preparation and use of chlorine for water treatment. Recipients also indicated a need for CATI implementers to engage community leaders. As CATIs are part of cholera control plans in many cholera-endemic countries, it is important to evaluate existing programs and develop evidence-based approaches to deliver CATIs that are both tailored to the local context and engage affected communities to increase WASH behaviors to reduce the spread of cholera.

Methods to Evaluate COVID-19 Preventive Hygiene Programs: Observed Mask Wearing, Handwashing, and Physical Distancing Behaviors in Public Indoor Spaces in Democratic Republic of the Congo.

The objective of our study was to develop and test observational methods to evaluate COVID-19 preventive hygiene behaviors and physical distancing, and to evaluate the effectiveness of a government mandate on indoor fully covered mask wearing. An observational study was conducted of 4,736 individuals from April to October 2021 using 5-hour and rapid (10-minute) structured observations and spot checks to evaluate mask-wearing, handwashing, and physical-distancing behaviors, and the functionality of handwashing stations in 161 indoor public spaces across Bukavu, Democratic Republic of the Congo (DRC). Sixteen percent of individuals entering indoor public spaces were wearing a mask that fully covered their nose and mouth (fully covered mask wearing). Fully covered mask wearing was lowest inside schools (1%), universities (2%), religious establishments (22%), and health facility wards (28%). Overall physical distancing of more than 1-m inside indoor public spaces was 22%, and was lowest inside schools and religious establishments (7%). Thirty-nine percent of handwashing stations had water and a cleansing agent present. Ten percent of individuals washed their hands with a cleansing agent before entering an indoor space. Overall, fully covered mask wearing was similar for 5-hour and rapid structured observations (16% versus 15%). The odds of fully covered mask wearing was significantly greater with increased government enforcement of mask wearing in public spaces through fines (odds ratio, 2.72; 95% CI, 1.02-7.30). This study presents rigorous methods using structured observations to assess government mandates and programs on COVID-19 preventive hygiene behaviors in indoor public spaces in settings globally.

A Qualitative Evaluation of COVID-19 Preventative Response Activities in South Kivu, Democratic Republic of the Congo.

OBJECTIVE: In this evaluation of COVID-19 preventative response programs in South Kivu, Democratic Republic of the Congo (DRC), we aimed to explore community understandings of COVID-19, assess operational successes and challenges of COVID response activities, and identify barriers to practicing COVID-19 preventative behaviors. METHODS: Thirty-one semi-structured interviews were conducted from April to September 2021 in South Kivu, DRC, with community members (n = 16) and programmatic stakeholders (n = 15) (healthcare providers, government officials, and developmental and NGO staff engaged in COVID-19 response). FINDINGS: Most community members were aware of COVID-19 and its global burden, but few were aware of local transmission in their area. Some community members attributed COVID-19 to actions of malevolent neighbors, miasma ("bad air"), or spirits. Awareness of COVID-19 preventative measures was widespread, largely because of radio and TV health promotion programs. Community members and programmatic stakeholders both said community-level non-compliance to COVID-19 preventative measures was high despite high awareness of preventative methods. Community members expressed concern that face masks distributed as part of preventative programs contained the COVID-19 virus. Programmatic stakeholders emphasized the need for broader health system strengthening with improved coordination, provision of resources to health facilities at the provincial level, and prioritization of research. Lessons learned from addressing Ebola were leveraged for COVID-19 health promotion, rapid training of healthcare personnel, and surveillance. CONCLUSIONS: Community-informed approaches are needed for effective COVID-19 preventative response programs in South Kivu, DRC. Our study identified successes and challenges in COVID-19 response activities. Future research should assess the effectiveness of integrating preventive programs with COVID-19 vaccination efforts.