Health-seeking behaviour in the city of Lubumbashi, Democratic Republic of the Congo: results from a cross-sectional household survey

Inventory of the best-selling medicinal plants on the Lubumbashi markets (DR Congo) and authentication of samples from the 3 most popular species

ETHNOPHARMACOLOGICAL RELEVANCE

Knowledge of the high-sale medicinal plants and their authentication are essential parameters to ensure the safety of people using herbal medicine and to plan the safeguarding of medicinal species threatened with extinction.

AIMS

The present study, carried out in Lubumbashi, Democratic Republic of Congo, aimed to geolocate medicinal plant sales points, list the best-selling species, and authenticate samples of the most popular species on the market.

METHODS

A survey was conducted among the medicinal plant sellers in Lubumbashi's markets and other public spaces, to identify the best-selling species. Samples of the species reported as the most sold were purchased for sales unit weight measurement, and authentication. For the 3 most popular plant species, the identity of 92 samples, purchased from some 25 herbalists, was assessed by combining the microscopic characteristics of powdered drugs with the HPTLC fingerprints of methanolic extracts; for each species, these samples were compared with 1 or 2 botanically authenticated reference samples. As abundant starch granules were detected by microscopy, some samples were suspected of heavy flour contamination, which was confirmed by an enzymatic determination of their starch content.

RESULTS

A total of 108 herbalists (48.1 % women) with a median age of 37 years (range, 20-67 years), and a median seniority of 5 years (0.7-30) were interviewed. From a total of 514 purchased samples, 396 (77.0 %) corresponded to 56 species that could be identified, including 92 samples representing the 3 most frequently sold plant species. The identities of 118 samples (having 82 different vernacular names), could not be determined, due to the lack of voucher specimen. Roots were the most sold organ (56.0 %; n = 514), mainly in powder form (78.7 %), and the median price was 21 USD/kg, at the time of the survey (January to May 2021). The identified specimens were, predominantly, the roots of Terminalia mollis M.A.Lawson (33.3 %), Securidaca longepedunculata Fresen (28.7 %), and stem barks of Nauclea pobeguinii Hua ex Pobég. (23.1 %); from the recorded sales figures, the amounts of material annually sold for these 3 species are estimated at about 5.7, 6.0, and 3.1 tons, respectively. Some sellers reported problems in identifying and/or preserving S. longepedonculata and T. mollis. Among the 92 samples analyzed for the three species, 18.5 % raised problems, including species substitutions (14/17), dilution with flour (1/17), dilution with flour and species substitution (1/17), and detection of a phytochemical variant (1/17), that could arise either from contamination by another species, a particular plant growth environment, or poor storage conditions.

CONCLUSION

The confusion/adulteration rate measured here for highly popular species is quite alarming (18.5 %); but, indeed, roots, especially as powders, are often difficult to differentiate based on the coarse organoleptic examination practiced by herbal traders. Microscopic and phytochemical characteristics reported in this study, quite easy to obtain with basic laboratory equipment, should be systematically applied by the health products regulatory authorities to control the quality of herbals and ensure that patients get the drug desired for their treatment.

Determinants of health seeking behaviour in South Sudan: a cross-sectional household survey

BACKGROUND

Access to healthcare is a major challenge in South Sudan, but evidence on the factors influencing health seeking behaviour (HSB) and the magnitude of their effect is limited. This study aims to identify which determinants are associated with seeking care for perceived health needs and with seeking care at private or public healthcare facilities in South Sudan.

METHODS

A cross-sectional household survey was conducted in three purposefully-selected states (Central Equatoria, Western Equatoria and Warrap). A multi-stage, cluster sampling design was used. Univariable and multivariable logistic regression models were computed to explore the relationships between seeking care for perceived health needs and choice of facility, and individual and household characteristics based on an adapted Levesque framework.

RESULTS

We identified that individuals who obtained medication (OR 2.45, 95% CI 1.15-5.23), obtained and paid for medication (OR 4.26, 95% CI 2.08-8.74), lived in Western-Equatoria (OR 9.05, 95% CI 2.35-34.54), and were aware of community health workers (CHWs) (OR 1.70, 95% CI 1.08-2.67), were significantly more likely to seek care for a perceived health need. Individuals who obtained and paid for medication (OR 3.03, 95% CI 1.59-5.81) and who lived further from a public health centre (OR 1.19, 95% CI 1.09-1.31) were more likely to seek care at a private facility, while individuals who had used the provider before (OR 0.52, 95% CI 0.34-0.78), lived in Western Equatoria (OR 0.24, 95% CI 0.13-0.46), lived in a rural household (OR 0.40, 95% CI 0.23-0.70) and had a longer travel time to the visited health facility, were less likely to seek care at a private facility.

CONCLUSIONS

Survey respondents' state of residence and awareness of CHWs were associated with health seeking, while their state of residence, age, whether they paid for medication or not, travel time and distance to facilities were associated with choice of facility. Our results suggest differences in patterns of HSB between states, but studies with larger sample sizes are needed to analyse this. Furthermore, qualitative studies into access to healthcare in South Sudan could help characterise the nature of determinants and their relationship.

Understanding the mix of services for mental health care in urban DR Congo: a qualitative descriptive study

BACKGROUND

Mental health workers (MHWs) are exposed to conflicts of competence daily when performing tasks related to the provision of mental health services. This may be linked to a lack of understanding of their tasks as caregivers and providers. Furthermore, in most low-income settings, it is unclear how the available services are organized and coordinated to provide mental health care. To understand the above, this study aimed to identify the current mix of services for mental health care in the urban Democratic Republic of the Congo (DRC).

METHODS

A qualitative descriptive study was carried out in Lubumbashi from February to April 2021. We conducted 7 focus group discussions (FGDs) with 74 key informants (family members, primary care physicians, etc.) and 13 in-depth interviews (IDIs) with key informants (traditional healers, psychiatrists, etc.). We performed a qualitative content analysis, guided by an analytical framework, that led to the development of a comprehensive inventory of MHWs from the household level to specialized facilities, exploring their tasks in care delivery, identifying existing services, and defining their current organization.

RESULTS

Analysis of transcripts from the FGDs and IDIs showed that traditional healers and family caregivers are the leading providers in Lubumbashi. The exploration of the tasks performed by MHWs revealed that lifestyle, traditional therapies, psychotherapy, and medication are the main types of care offered/advised to patients. Active informal caregivers do not currently provide care corresponding to their competencies. The rare mental health specialists available do not presently recognize the tasks of primary care providers and informal caregivers in care delivery, and their contribution is considered marginal. We identified five types of services: informal services, traditional therapy services, social services, primary care services, and psychiatric services. Analyses pointed out an inversion of the ideal mix of these services.

CONCLUSIONS

Our findings show a suboptimal mix of services for mental health and point to a clear lack of collaboration between MHWs. There is an urgent need to clearly define the tasks of MHWs, build the capacity of nonspecialists, shift mental health-related tasks to them, and raise awareness about collaborative care approaches.

The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low- and middle-income countries

BACKGROUND

The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs.

METHODS

This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs.

RESULTS

We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality.

CONCLUSIONS

Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

[Choix thérapeutiques des hypertendus et diabétiques en milieu rural : Une étude mixte dans deux zones de santé de l'Est de la République Démocratique du Congo]

Therapeutic choices of hypertensive and diabetics in rural areas: A mixed study in two health zones in the East of the Democratic Republic of Congo.

BACKGROUND

One third of patients in the Democratic Republic of Congo (DRC) do not use the formal health system to access healthcare.

AIM

In this manuscript we analyse the therapeutic decisions of hypertensive and diabetic patients in rural eastern DRC and the reasons for these decisions.

SETTING

The study was conduct in two health zones (HZ) in South Kivu (Bagira and Walungu), DRC.

METHODS

A mixed-methods convergent study was conducted from November 2018 to December 2018. Quantitative data were collected using a questionnaire and qualitative data were collected using focus groups. The quantitative data were analysed using descriptive statistics and a Fischer exact test, while the qualitative data were analysed using thematic analysis.

RESULTS

Out of 382 subjects declaring a chronic pathology, hypertensives and diabetics represented 21.5% and 7.9%, respectively. Health facilities were the first therapeutic choice of the chronically affected persons. The alternative therapeutic choices found were the use of prayer rooms, consultation with traditional healers and self-medication. Poverty, ignorance, the pharmaceutical business, and the socio-cultural dimension of the disease are the main causes of alternative therapeutic choices for hypertensives and diabetics.

CONCLUSION

To ensure appropriate care for patients with chronic diseases in rural areas, it is important to establish a bridge of regulated collaboration between the formal and informal health sector.

Antibiotic use prior to seeking medical care in patients with persistent fever: a cross-sectional study in four low- and middle-income countries

OBJECTIVES

Community-level antibiotic use contributes to antimicrobial resistance, but is rarely monitored as part of efforts to optimize antibiotic use in low- and middle-income countries (LMICs). We investigated antibiotic use in the 4 weeks before study inclusion for persistent fever.

METHODS

The NIDIAG-Fever (Neglected Infectious diseases DIAGnosis-Fever) study investigated aetiologies of infections in patients ≥5 years old with fever ≥1 week in six healthcare facilities in Cambodia, the Democratic Republic of the Congo (DRC), Nepal, and Sudan. In the present nested cross-sectional study, we describe prevalence and choice of antibiotics before and at study inclusion, applying the Access/Watch/Reserve (AWaRe) classification of the WHO List of Essential Medicines. Factors associated with prior antibiotic use were analysed.

RESULTS

Of 1939 participants, 428 (22.1%) reported the prior use of one or more antibiotics, ranging from 6.3% (24/382, Cambodia) to 35.5% (207/583, Nepal). Of 545 reported antibiotics, the most frequent were Watch group antibiotics (351/545, 64.4%), ranging from 23.6% (DRC) to 82.1% (Nepal). Parenteral administration ranged from 5.9% to 69.6% between study sites. Antibiotic use was most frequent among young patients (5-17 years of age; risk ratio 1.42, 95%CI 1.19-1.71) and men (RR 1.29; 95%CI 1.09-1.53). No association was found with specific symptoms. Of 555 antibiotics started before study inclusion, 275 (49.5%) were discontinued at study inclusion.

CONCLUSIONS

Watch antibiotics were frequently used, and discontinued upon study inclusion. The antibiotic use frequency and choice varied importantly between LMICs. Data on local antibiotic use are essential to guide efforts to optimize antibiotic use in LMICs, should not be restricted to hospitals, and need to take local healthcare utilization into account.

Inequalities in the access to and quality of healthcare in Mozambique: evidence from the household budget survey

OBJECTIVES

To assess the inequalities in the access to and quality of care and its related direct payments.

DESIGN

Secondary analysis of the cross-sectional Mozambican Household Budget Survey (HBS).

SETTING

Nationally-representative sample of households in Mozambique.

PARTICIPANTS

11 480 households (58 118 individuals) interviewed during HBS 2014/15.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Equity, utilization of healthcare, access to quality care and direct payments.

RESULTS

About 12.2% of women and 10.1% of men of the survey report a perceive health need. About 72.1% of women and 72.9% men use healthcare. Population in a disadvantaged position living in rural areas have less probabilities of using healthcare for equal health compared to the individuals of a wealthier position and living in urban settings. With regard to quality care, 47.7% women and 46.8% men do not report quality problems. No differences for women's wealth. Men in a disadvantaged position report less chances of accessing quality care compared to men of advantaged position. Also, women and men living in rural areas have less probabilities of accessing quality care. Finally, the majority of people who access healthcare paid 1 Mt during their visit.

CONCLUSIONS

This study tackles a fundamental policy concern for health systems of Sub-Saharan Africa and points to areas that urge action to address the existent of socioeconomic and geographical inequalities in the access to and quality of care for women and men, including the strengthening of health facilities in rural and deprived areas to ensure that access to adequate care of acceptable quality is distributed according to need.

Assessing the preparedness of primary healthcare facilities during a cholera outbreak in Kinshasa, Democratic Republic of the Congo, 2018

OBJECTIVE

During the 2017-2018 cholera outbreak in Kinshasa, many patients initially reported to primary healthcare centers (HCs) before being transferred to the nearest cholera treatment centers. This study aims to assess the level of preparedness of HCs in responding to cholera outbreaks.

STUDY DESIGN

Descriptive cross-sectional survey.

METHODS

We conducted a descriptive cross-sectional survey in 180 of 374 primary HCs in Kinshasa. We collected data on 14 cholera preparedness criteria and described their prevalence among HCs. We used logistic regression to assess the association between each preparedness criteria and previous reporting of cholera cases by HCs.

RESULTS

The median number of preparedness criteria met by HCs was 5 [range: 0-11]. Five percent (n = 9) of HCs [95% confidence interval (CI): 2.3%-9.3%] met at least 10 criteria. HCs that previously reported ≥3 cholera cases were less likely to meet the criteria for 'presence of an isolation unit' (adjusted odds ratio [aOR]: 0.12; 95% CI [0.03-0.61]) and 'availability of sufficient quantity of chlorine' (aOR: 0.13; 95% CI [0.02-0.64]).

CONCLUSIONS

Despite past experience of cholera cases, health facilities in Kinshasa exhibit a low level of cholera preparedness. There is a need to prioritize the reinforcement of the preparedness of primary HCs to prevent future cholera outbreaks.

Determinants of healthcare seeking and out-of-pocket expenditures in a "free" healthcare system: evidence from rural Malawi

BACKGROUND

Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services.

METHODS

Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place.

RESULTS

Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p₂ = 0.018; p₃ = 0.001; p₄ = 0.002), and urban residency (p = 0.001).

CONCLUSION

Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.

Hospital detention of mothers and their infants at a large provincial hospital: a mixed-methods descriptive case study, Lubumbashi, Democratic Republic of the Congo

Background

The practice of detaining people who are unable to pay for health care services they have received is widespread in many parts of the world. We aimed to determine the proportion of women and their infants detained for inability to pay for services received at a provincial hospital in the Democratic Republic of the Congo during a 6-week period in 2016. A secondary objective was to determine clinical and administrative staff attitudes and practices about payment for services and detention.

Methods

This mixed-methods descriptive case study included a cross-sectional survey and interviews with key informants.

Results

Over half (52%) of the 85 women who were in the maternity ward at Sendwe Hospital and eligible for discharge between August 5 and September 15, 2016 were detained for 1 to 30 days for outstanding bills of United States dollars (USD) 21 to USD 515. Women who were detained were younger, poorer, and had more obstetric complications and caesarean sections than other women. In addition, over one quarter of the infants born to these women had died during delivery or in the first three days of life. Key informant interviews normalized detention as an unfortunate but inevitable consequence of patient poverty and health system resource constraints.

Conclusions

Detention of women and their infants is common at this hospital in the DRC. This represents a violation of human rights and a systemic failure to ensure that all people have access to essential health services and that they not suffer financial hardship due to the price of those services.

Appraisal of Healthcare-seeking Behavior and Prevalence of Workplace Injury among Artisans in Automobile Site in Abakaliki, Southeast Nigeria

Background:

Healthcare-seeking behavior is a decision-making process governed by an individual's conduct, community norms, and expectations, as well as provider-related characteristics and manners. This study determined factors associated with healthcare seeking behavior of automobile artisans in Abakaliki.

Materials and Methods:

A descriptive cross-sectional survey of 380 artisans was carried out. Respondents were selected using multi-stage sampling method and semi-structured interviewer administered pretested questionnaire was used to gather information. Data were analyzed using SPSS software, and the Chi-squared test was used to test for association at 5% level of significance.

Results:

The mean age of the artisans was 31.3 ± 10.3 years, and the mean monthly income was N15277. Less than half of the respondents (47.7%) sought medical care in pharmacy/patent medicine stores. A significant association was found between distance to the facility for medical care and period of delay before seeking care (P = 0.01). Bruises (45.3%) and cuts (32.3%) were the most prevalent injuries sustained in the preceding 12 months. A significantly high proportion of those who had bruises and cuts traveled >6 km to seek care and less than half of the respondents (47.6%) who reside within 5 km radius to place of medical care patronized pharmacy/patent medicine shops. However, higher proportion of those with cuts (52.0%) and burns (62.5%) compared to other types of injury went to the hospitals no matter the distance.

Conclusions:

The artisans have poor health-seeking behavior and majority sought medical care in pharmacy/patent medicine shops rather than hospitals. However, a significant proportion of those with injuries used hospitals regardless of the distance. It is, therefore, imperative to establish healthcare facilities within 5 km radius from where they live and work.

Characterization of pharmaceutical medication without a medical prescription in children before hospitalization in a resource-limited setting, Cameroon

Introduction

The use of different therapeutic approaches is common among sick children in Cameroon. The main objective of this study was to characterize the use of non-prescription drugs and describe the therapeutic itineraries of sick children before admission to the hospital.

Methods

A cross-sectional and prospective study was conducted from January to May 2017. A closed-ended questionnaire (CEQ) consisting of one or several response options was administered to the parents/guardians of the children on admission to the hospital in the pediatric ward of the Laquintinie Hospital in Douala (LHD) and the Cité des Palmiers District Hospital (CPDH) of the city of Douala. Inclusion of participants was made consecutively for adolescents who gave their consent and parents or guardians who signed the informed consent for all children. The confidentiality of the data was ensured by the replacement of the names by codes.

Results

Overall, 295 hospitalized children were included with an average age of 3.1 (SD: 3.3) years in the study. More than half of these children (58.6%) came from LHD. More than 90% of parents had at least one therapeutic recourse (TR). The ratio of boys to girls 3/1. Self-medication (74.1%) and medical consultation (16.9%) were the main therapeutic paths in 1^st recourse. The medical consultation (80.2%) and the pharmaceutical advice (16.9%) were used frequently in 2^nd recourse. The mean lapse time to see a medical professional was 2.7 days (min-max: 0-14 days). The main symptoms associated with TR were fever (76.6%), vomiting (24.7%) and diarrhea (22.7%). The most frequently used drugs were Analgesics/antipyretics (47.6%), antimalarials (15.0%) and antibiotics (10.2%) and the family medicine box was the highest source of drugs.

Conclusion

Self medication remains the first therapeutic path, followed by medical consultation as second therapeutic path taken when the disease is perceived as serious.

[External anthropometric measurement and pelvimetry among nulliparous women in Lubumbashi: risk factors and predictive score of mechanical dystocia]

INTRODUCTION

Maternal and perinatal morbi-mortality is higher in most of sub-Saharan Africa compared to the rest of the world. All women at risk for mechanical dystocia should be screened before labor and referred to a better equipped Hospital for childbirth. This would reduce morbi-mortality. This study aims to develop a predictive score of mechanical dystocia during childbirth among nulliparous Congolese women.

METHODS

We conducted a cross-sectional study of nulliparous women with single pregnancy in 7 Maternity Units in the city of Lubumbashi (DRC). Women' size, weight, and external pelvimetry results were collected and analyzed. Univariate and multivariate analyses were performed. Discrimination score was assessed using the ROC curve.

RESULTS

We included in the study 535 nulliparous women, of whom 126 (23.55%) had given birth by cesarean section due to mechanical dystocia. After logistic modelling, three criteria emerged as predictive factors for mechanical dystocia: maternal height <150 cm (adjusted OR=2.96 [1,49-5,87]), bi-ischiatic diameter <8 cm (adjusted OR =15.96 [3,46-73,56]), and Trillat's pre-pubic diameter <11 cm (adjusted OR =2.34 [1,36-4,01]). The area under the ROC curve of the score was 0.6549 with a sensitivity of 23.81%, a specificity of 97.80% and a positive predictive value of 76.92%.

CONCLUSION

It has been observed that 10th percentile of the three maternal anthropometric measures was predictive of mechanical dystocia. When they were used together, these three values allowed for the development of lowest-cost screening score for use in low income settings.

The Quality of Medicines Used in Children and Supplied by Private Pharmaceutical Wholesalers in Kinshasa, Democratic Republic of Congo: A Prospective Survey

Poor-quality medicines are a threat to public health in many low- and middle-income countries, and prospective surveys are needed to inform corrective actions. Therefore, we conducted a cross-sectional survey on a sample of products used for children and available in the private market in Kinshasa, Democratic Republic Congo: amoxicillin (AX) and artemether/lumefantrine (AL), powders for suspension, and paracetamol (PC) tablets 500 mg. Overall, 417 products were covertly purchased from 61 wholesalers. To obtain a representative sample, the products were weighted on their market shares and a subset of 239 samples was randomly extracted to undergo in-depth visual inspection locally, and they were chemically assessed at two accredited laboratories in Belgium. Samples were defined of “poor-quality” if they failed to comply with at least one specification of the International Pharmacopoeia (for AL) or United States Pharmacopoeia 37 (for AX and PC). Results are reported according to the Medicine Quality Assessment Reporting Guideline. The visual inspection detected nonconformities in the aspects of antimalarial powders for suspension, and poor-quality labels across all medicine types. According to chemical analysis, 27.2% samples were of poor quality and 59.5% of AL samples were underdosed in artemether. Poor quality was more frequent for locally manufactured antimalarials (83.3%, P = 0.021; 86.4%, P = 0.022) and PC (4.8%, P = 0.000). The poor quality of the surveyed products may decrease the treatment’s efficacy and favor the development of resistances to antimalarials. It is hoped that these findings may guide the corrective actions of the Democratic Republic of Congo Regulatory Authority, which was the main partner in the research.

[Risk factors for maternal and perinatal mortality among women undergoing cesarean section in Lubumbashi, Democratic Republic of Congo II]

Introduction

L’objectif était d’analyser les facteurs de risque de mortalité maternelle et périnatale de la césarienne à Lubumbashi, République Démocratique du Congo (RDC).

Méthodes

Étude multicentrique de 3643 césariennes réalisées entre le 1er janvier 2009 et le 31 décembre 2013 sur un total de 34199 accouchements dans cinq formations hospitalières de référence à Lubumbashi (RDC). Les données sociodémographiques, les indications, l’environnement obstétrical et la morbi-mortalité maternelles et périnatales ont été analysés au logiciel Epi Info 2011. Les fréquences calculées sont exprimées en pourcentage et les moyennes avec leurs écart-types. Le test de Chi-carré et le test exact de Fisher lorsque recommandés ont été utilisés pour la comparaison des fréquences. L’odds ratio a été calculé avec l’intervalle de confiance de 95% de Cornfield grâce à un modèle de régression logistique pour déterminer la puissance de facteurs de risque. Le seuil de signification a été fixé à p < 0,05.

Résultats

La fréquence de la césarienne était de 10,65%. L'âge moyen des césarisées était de 28,83±6,8 ans (extrêmes: 14 et 49 ans). La parité variait de 1 à 16 avec une moyenne de 2,6. De ces opérées, une sur neuf (10,9%) était porteuse d’un utérus cicatriciel de césarienne antérieure et 22,3% étaient des évacuées obstétricales. Les taux de létalité maternelle et périnatale étaient respectivement de 1,4% et 7,07% lors de la césarienne. L’analyse des facteurs de risque montre que la grande multiparité (≥5), l’absence de surveillance de la grossesse, le caractère urgent de l’indication opératoire influent significativement sur la mortalité maternelle. A ces facteurs s’ajoutent pour la mortalité périnatale l’âge maternel avancé (> 35 ans), l’évacuation comme mode d’admission et l’immaturité fœtale.

Conclusion

Cette étude montre que la césarienne dans nos conditions de travail est couplée à une forte mortalité maternelle et périnatale. Les facteurs de risque identifiés sont en grande partie évitables, surtout à tort ou à raison imputés à l’opération masquant ipso facto les circonstances souvent irrationnelles de sa pratique.

Introduction

The objective was to analyze risk factors for maternal and perinatal mortality among women undergoing cesarean section in Lubumbashi, Democratic Republic of Congo (DRC).

Methods

We conducted a multicenter study of 3643 women undergoing cesarean sections between 1 January 2009 and 31 December 2013 out of 34199 women delivering in five general referral hospitals in Lubumbashi (DRC). Sociodemographic data, indications, obstetrical environment as well as maternal and perinatal morbi-mortality were analyzed using Epi Info 2011 software. Computed frequencies were expressed in percentage and mean values were expressed in terms of standard deviations. Chi-square test and Fisher’s exact test, when recommended, were used to compare frequencies. The odds ratio was calculated using Cornfield 95% confidence interval based on a logistic regression model in order to determine the strength of risk factors. Threshold significance level was set at p < 0.05.

Results

The frequency of cesarean sections was 10.65%. The average age of women undergoing cesarean section was 28.83 ± 6.8 years (with a range from 14 to 49 years). Parity ranged from 1 to 16 with an average of 2.6. 1 out of 9 (10.9%) women undergoing cesarean section were patients with previous caesarean section uterine scar on the anterior wall of the uterus and 22.3% of women were patients with previous obstetric evaquation. Maternal and perinatal mortality rate was 1.4% and 7.07% during cesarean section respectively. The analysis of risk factors shows that the great multiparity (≥5), the absence of monitoring during pregnancy, the urgent nature of emergency surgery significantly affect maternal mortality. Other factors for perinatal mortality included advanced maternal age (>35 years), patients referral from one facility to another as a mode of admission and fetal immaturity.

Conclusion

This study shows that cesarean section in our working condition is associated to a significant maternal and perinatal mortality. Identified risk factors are largely preventable, because they are rightly or wrongly ascribed to cesarean section glossing over, ipso facto, the often irrational circumstances of its practice.

Health-Seeking Behaviour towards Poverty-Related Disease (PRDs): A Qualitative Study of People Living in Camps and on Campuses in Cameroon

Poverty-Related Diseases (PRDs) emphasize poverty as a ‘breeding-ground’ for a range of diseases. The study presented here starts from the premise that poverty is a general condition that can limit people’s capacity to prevent, mitigate or treat diseases. Using an interpretation of health seeking behaviour (HSB), inspired by the salutogenic approach, we investigated how people deal with PRDs, their ability and strategies put in place to cope. We collected HSB data from two groups of respondents in Cameroon: labourers of the Cameroon Development Corporation (CDC) living in settlements called camps and students of the state universities of Buea and Yaoundé living in settlements we refer to as campuses. By selecting these groups, the study offers a unique view of how different people cope with similar health challenges. We carried out semi-structured interviews with 21 camp dwellers and 21 students in a cross-sectional study. Our findings revealed 1) respondents use multiple resources to cope with PRDs. 2) Respondents’ perceptions of diseases and connection with poverty closely ties to general hygienic conditions of their living environment. 3) Utilisation of health facilities is not strongly dependent on financial resources. 4) Volatile health facilities are a major challenge and reason for people to revert to other health resources. The study brings out the need for organisations (governmental and non-governmental) to strengthen people’s capacities to cope with health situations through better health and housing policies geared at incorporating practices currently used by the people and supporting pro-hygienic initiatives.

People’s living conditions are a crucial factor for health and diseases. In developing countries like Cameroon, poverty is a major condition affecting the way people deal with health issues. We studied people’s a health-seeking behaviour action in two settings: camps, housing labourers of the Cameroon Development Cooperation, and campuses, places where students of the state universities of Buea and Yaoundé reside. We interviewed 21 camp dwellers and 21 students about their health challenges and responses. The results show health challenges not only relate to exposure to diseases but also to the reliability, affordability and functionality of medical services, the hygienic conditions in the living environment and money. For treatment of common diseases, foremost malaria and typhoid, the last resort was going to a clinic or hospital. More prominent responses were cleaning and other hygienic measures, self-medication using available tablets, herbs or other traditional medicine, consultation at small pharmacies or unofficial ‘doctors’. Public health services should anticipate people’s health behaviour to better address the health challenges of people living in poor conditions.

Determinants of Healthcare Utilisation and Out-of-Pocket Payments in the Context of Free Public Primary Healthcare in Zambia

BACKGROUND

Access to appropriate and affordable healthcare is needed to achieve better health outcomes in Africa. However, access to healthcare remains low, especially among the poor. In Zambia, poor access exists despite the policy by the government to remove user fees in all primary healthcare facilities in the public sector. The paper has two main objectives: (i) to examine the factors associated with healthcare choices among sick people, and (ii) to assess the determinants of the magnitude of out-of-pocket (OOP) payments related to a visit to a health provider.

METHODS

This paper employs a multilevel multinomial logistic regression to model the determinants of an individual's choice of healthcare options following an illness. Further, the study analyses the drivers of the magnitude of OOP expenditure related to a visit to a health provider using a two-part generalised linear model. The analysis is based on a nationally representative healthcare utilisation and expenditure survey that was conducted in 2014.

RESULTS

Household per capita consumption expenditure is significantly associated with increased odds of seeking formal care (odds ratio [OR] = 1.12, P = .000). Living in a household in which the head has a higher level of education is associated with increased odds of seeking formal healthcare (OR = 1.54, P = .000) and (OR = 1.55, P = .01), for secondary and tertiary education, respectively. Rural residence is associated with reduced odds of seeking formal care (OR = 0.706, P = .002). The magnitude of OOP expenditure during a visit is significantly dependent on household economic well-being, distance from a health facility, among other factors. A 10% increase in per capita consumption expenditure was associated with a 0.2% increase in OOP health expenditure while every kilometre travelled was associated with a K0.51 increase in OOP health expenditure.

CONCLUSION

Despite the removal of user fees on public primary healthcare in Zambia, access to healthcare is highly dependent on an individual's socio-economic status, illness type and region of residence. These findings also suggest that the benefits of free public healthcare may not reach the poorest proportionately, which raise implications for increasing access in Zambia and other countries in sub-Saharan Africa.

Health Care Seeking Behavior in Southwest Ethiopia

Background

Rural and urban populations have disparate socio-demographic and economic characteristics, which have an influence on equity and their health seeking behavior. We examined and compared the health care seeking behavior for perceived morbidity between urban and rural households in Southwest Ethiopia.

Methods

Analytic cross-sectional study was conducted among urban and rural households living in Esera district of Southwest Ethiopia. A random sample of 388 head of households (126 urban and 262 rural) were selected. A pretested and structured questionnaire was used for data collection with face-to-face interview. In addition to descriptive methods, binary logistic regression was used to identify factors associated with health seeking behavior at p value of less than 0.05.

Results

Of the sample household heads, 377 (97.2%) (119 urban and 258 rural) were successfully interviewed. Among these, 58.4% (95% CI, 53.3–63.3%) of the households sought care from modern health care that was lower among rural (48.1%) than urban (80.7%) households. The prevalence of self-treatment was 35.3% in urban and 46.1% in rural households. Among the factors considered for modern health care utilization, higher monthly income (AOR, 5.6; 95% CI, 2.04–15.4), perceived severity of disease (AOR, 2.5; 95% CI, 1.1–5.8), acute duration of disease (AOR, 8.9; 95% CI, 2.4–33.3) and short distance from health facilities (AOR, 3; 95% CI, 1.2–8.4) among rural and being married (AOR, 11.3; 95% CI, 1.2–110.2) and perceived severity of disease (AOR, 6.6; 95% CI, 1.1–10.9) among urban households showed statistically significant association.

Conclusions

The general health seeking behavior of households on perceived morbidity was satisfactory but lower in rural compared to urban households. Self-medication was also widely practiced in the study area. The findings signal the need to work more on accessibility and promotion of healthcare seeking behavior especially among rural households.

Human rabies: a descriptive observation of 21 children in Kinshasa, the Democratic Republic of Congo

OBJECTIVES

Human rabies has recently emerged as a significant public health threat in Kinshasa, Democratic Republic of Congo (DRC). However, there is little epidemiological information on human rabies especially in children.

METHODS

We performed at Pediatrics Department of General Reference hospital of Kinshasa between December 2008 and July 2009, a retrospective study to assess the incidence and to describe their clinical aspects and outcome.

RESULTS

A total of 21 cases were observed, rather three cases per month. There were 12 boys (57·1%) and 9 girls (42·9%). Biting animal was found to be dog in all cases (100%). The dog was not immunized in all of cases. On admission, all patients (100%) showed furious rabies manifestations. Only two (9·5%) had their wounds treated and received an anti-rabies vaccine (ARV) after the bite incident. Two (9·5%) patients received rabies immunoglobulin (RIG). The case-fatality rate was 100%.

CONCLUSIONS

The disease emerges as a new major public health problem because of a lack of knowledge regarding rabies risk, the poor management of dog bites. Preventative vaccination for rabies should be recommended in the population of Kinshasa, area at high risk to contract rabies, particularly in children.

Traditional medicine for the rich and knowledgeable: challenging assumptions about treatment-seeking behaviour in rural and peri-urban Nepal

Traditional medicine is commonly assumed to be a crucial health care option for poor households in developing countries. However, little research has been done in Asia to quantify the reliance on traditional medicine and its determinants. This research contributes to filling in this knowledge gap using household survey data collected from 571 households in three rural and peri-urban sites in Nepal in 2012. Questions encompassed household socioeconomic characteristics, illness characteristics, and treatment-seeking behaviour. Treatment choice was investigated through bivariate analyses. Results show that traditional medicine, and especially self-treatment with medicinal plants, prevail as treatment options in both rural and peri-urban populations. Contrarily to what is commonly assumed, high income is an important determinant of use of traditional medicine. Likewise, knowledge of medicinal plants, age, education, gender and illness chronicity were also significant determinants. The importance of self-treatment with medicinal plants should inform the development of health policy tailored to people's treatment-seeking behaviour.

Care seeking behaviour for children with suspected pneumonia in countries in sub-Saharan Africa with high pneumonia mortality

Pneumonia is the leading cause of childhood mortality in sub-Saharan Africa (SSA). Because effective antibiotic treatment exists, timely recognition of pneumonia and subsequent care seeking for treatment can prevent deaths. For six high pneumonia mortality countries in SSA we examined if children with suspected pneumonia were taken for care, and if so, from which type of care providers, using national survey data of 76530 children. We also assessed factors independently associated with care seeking from health providers, also known as 'appropriate' providers. We report important differences in care seeking patterns across these countries. In Tanzania 85% of children with suspected pneumonia were taken for care, whereas this was only 30% in Ethiopia. Most of the children living in these six countries were taken to a primary health care facility; 86, 68 and 59% in Ethiopia, Tanzania and Burkina Faso respectively. In Uganda, hospital care was sought for 60% of children. 16-18% of children were taken to a private pharmacy in Democratic Republic of Congo (DRC), Tanzania and Nigeria. In Tanzania, children from the richest households were 9.5 times (CI 2.3-39.3) more likely to be brought for care than children from the poorest households, after controlling for the child's age, sex, caregiver's education and urban-rural residence. The influence of the age of a child, when controlling for sex, urban-rural residence, education and wealth, shows that the youngest children (<2 years) were more likely to be brought to a care provider in Nigeria, Ethiopia and DRC. Urban-rural residence was not significantly associated with care seeking, after controlling for the age and sex of the child, caregivers education and wealth. The study suggests that it is crucial to understand country-specific care seeking patterns for children with suspected pneumonia and related determinants using available data prior to planning programmatic responses.