COVID-19 Vaccine Coverage and Factors Associated with Vaccine Hesitancy: A Cross-Sectional Survey in the City of Kinshasa, Democratic Republic of Congo

Vaccination against COVID-19 has been the main strategy used by most countries to limit the spread of the virus. However, vaccine uptake has been low in Africa, leading to the implementation of several interventions in order to improve vaccine coverage. This study was conducted due to the lack of information about COVID-19 vaccine coverage and the factors associated with vaccine hesitancy. This cross-sectional study was carried out in Kinshasa city using multi-stage random sampling. A total of 2160 households were included in this study. The data were analyzed using Stata 17 software. The means and standard deviations were computed for continuous data that followed a normal distribution, whereas proportions together with their 95% confidence intervals (CIs) were computed for categorical variables. The connections between dependent variables and each independent variable were tested using either Pearson's chi-square test or Fisher's exact test. The logistic regression method was employed to determine the factors that are linked to hesitation in obtaining the COVID-19 immunization. The majority of respondents were aged between 25 and 34 and 35 and 49 (28.9%). During this study, 15% (95% CI [13.25-17.9]) of respondents had received at least one dose of the COVID-19 vaccine. The prevalence of vaccine hesitancy was 67% (CI95%:64.9-69.1). Among the reasons given for refusing to be vaccinated, most respondents cited concerns about the vaccine being unsafe or causing adverse reactions (45%). Among the reasons given for accepting the vaccine, 26% thought that the vaccine prevented superinfection. The factors associated with hesitancy toward the COVID-19 vaccine were female gender, an age of less than 35 years, and living in non-slum households. Despite the interventions implemented across the country, the reluctance to be vaccinated remains a problem; this could lead to poor health outcomes, especially among the elderly and those with pre-existing conditions. It is important to step up awareness-raising campaigns in the community in order to increase the uptake of vaccination.

Predictors of mortality among inpatients in COVID-19 treatment centers in the city of Butembo, North Kivu, Democratic Republic of Congo

Determining the risk factors for severe disease and death among hospitalized Covid-19 patients is critical to optimize health outcomes and health services efficiency, especially in resource-constrained and humanitarian settings. This study aimed to identify the predictors of mortality of Covid-19 patients in North Kivu province in the Democratic Republic of Congo.A retrospective cohort study was conducted in 6 Covid-19 treatment centers in the city of Butembo from 1 January to 31 December 2021. The time to event (death), the outcome variable, was visualized by Kaplan-Meier curves and the log-rank test was used to confirm differences in trends. Cox regression was used for all the predictors in the bivariate analysis and multivariate analysis was done using predictors found statistically significant in the bivariate analysis. The following variables were considered for inclusion to the Cox regression model: Age, Sex, Disease length, Treatment site, History of at least one co-morbidity, Body mass index, Stage according to SpO2 and the NEWS-modified score.Among the 303 participants (mean age of 53 years), the fatality rate was 33.8 deaths per 1000 patient-days. Four predictors were independently associated with inpatient death: age category (≥ 60 years) (adjusted HR: 9.90; 95% CI: 2.68-36.27), presence of at least one comorbidity (adjusted HR: 11.39; 95% CI: 3.19-40.71); duration of illness of > 5 days before hospitalization (adjusted HR:1.70, 95% CI: 1.04-2.79) and peripheral capillary oxygen saturation (SpO2) < 90% (adjusted HR = 14.02, 95% CI: 2.23-88.32). In addition to advanced age, comorbidity, and length of disease before hospitalization, ambient air SpO2 measured by healthcare providers using low-tech, affordable and relatively accessible pulse oximetry could inform the care pathways of Covid-19 inpatients in resource-challenged health systems in humanitarian settings.

Evaluation of the effect of the Momentum project on family planning outcomes among first-time mothers aged 15-24 years in Kinshasa, DRC

OBJECTIVES

This article presents the effect of Momentum, a nursing student-led community-based service delivery project, on postpartum family planning (FP) outcomes among first-time mothers in Kinshasa, Democratic Republic of the Congo.

STUDY DESIGN

We employed a quasi-experimental design, with three intervention and three comparison health zones (HZ). Data were collected through interviewer-administered questionnaires in 2018 and 2020. The sample consisted of 1927 nulliparous women aged 15-24 years who were 6 months pregnant at baseline. Random effects and treatment effects models were used to assess the effect of Momentum on 14 postpartum FP outcomes.

RESULTS

The intervention group was associated with a unit increase of 0.6 (95% confidence interval [CI]: 0.4, 0.8)) in contraceptive knowledge and personal agency (95% CI: 0.3, 0.9), a unit decrease of 0.9 (95% CI: -1.2, -0.5) in the number of FP myths/misconceptions endorsed, and percentage point increases of 23.4 (95% CI: 0.2, 0.3) in FP discussion with a health worker, 13.0 (95% CI: 0.1, 0.2) in obtaining a contraceptive method within 6 weeks of delivery, and 13.3 (95% CI: 0.1, 0.2) in modern contraceptive use within 12 months of delivery. Intervention effects included percentage point increases of 5.4 (95% CI: 0.0, 0.1) in partner discussion and 15.4 (95% CI: 0.1, 0.2) in perceived community support for postpartum FP use. The level of exposure to Momentum was significantly associated with all behavioral outcomes.

CONCLUSIONS

The study demonstrated the effect of Momentum on increased postpartum FP-related knowledge, perceived norms, personal agency, partner discussion, and modern contraceptive use.

IMPLICATIONS

Community-based service delivery by nursing students can potentially lead to improved postpartum FP outcomes among urban adolescent and young first-time mothers in other provinces of the Democratic Republic of the Congo and other African countries.

Abortion care availability, readiness, and access: linking population and health facility data in Kinshasa and Kongo Central, DRC

BACKGROUND

The Democratic Republic of Congo (DRC) legalized abortion in 2018 to preserve health and pledged to provide quality postabortion care (PAC), yet little is known about the availability of abortion care services and if facilities are prepared to provide them; even less is known about the accessibility of these services. Using facility and population-based data in Kinshasa and Kongo Central, this study examined the availability of abortion services, readiness of facilities to provide them, and inequities in access.

METHODS

Data on 153 facilities from the 2017-2018 DRC Demographic and Health Survey Service Provision Assessment (SPA) were used to examine signal functions and readiness of facilities to provide services across three abortion care domains (termination of pregnancy, basic treatment of abortion complications, and comprehensive treatment of abortion complications). To examine PAC and medication abortion provision before and after abortion decriminalization, we compared estimates from the 2017-2018 SPA facilities to estimates from the Performance Monitoring for Action (PMA) data collected in 2021 (n = 388). Lastly, we assessed proximity to PAC and medication abortion using PMA by geospatially linking facilities to representative samples of 2,326 and 1,856 women in Kinshasa and Kongo Central, respectively.

RESULTS

Few facilities had all the signal functions under each abortion care domain, but most facilities had many of the signal functions: overall readiness scores were > 60% for each domain. In general, readiness was higher among referral facilities compared to primary facilities. The main barriers to facility readiness were stock shortages of misoprostol, injectable antibiotics, and contraception. Overall, provision of services was higher post-decriminalization. Access to facilities providing PAC and medication abortion was almost universal in urban Kinshasa, but patterns in rural Kongo Central showed a positive association with education attainment and wealth.

CONCLUSION

Most facilities had many of the necessary signal functions to provide abortion services, but the majority experienced challenges with commodity availability. Inequities in accessibility of services also existed. Interventions that address supply chain challenges may improve facility readiness to provide abortion care services, and further efforts are needed to narrow the gap in accessibility, especially among poor women from rural settings.

Is stunting in children under five associated with the state of vegetation in the Democratic Republic of the Congo? Secondary analysis of Demographic Health Survey data and the satellite-derived leaf area index

Background

The prevalence of stunting in the Democratic Republic of the Congo (DRC) is one of the highest globally. However, only a few studies have attempted to measure the association between stunting and vegetation, which is an important food source. The leaf area index (LAI) is an excellent measure for the vegetation state.

Objective

This paper intended to measure the association between the LAI and stunting among children under five years of age in the DRC. Its aim was to better understand the boundary conditions of stunting and explore potential links to climate and environmental change.

Methods

This paper adopts a secondary data analysis approach. We used data on 5241 children from the DRC Demographic Health Survey (DHS) 2013-2014, which was collected from a nationally representative cross-sectional survey. We used the satellite-derived LAI as a measure for the state of vegetation and created a 10-km buffer to extract each DHS cluster centroid's corresponding mean leaf-area value. We used a generalised mixed-effect logistic regression to measure the association between LAI and stunting, adjusting the model for mother's education, occupation and birth interval, as well as child's age and national wealth quintile. A height-for-age Z-score (HAZ) was calculated and classified according to WHO guidelines.

Results

Children in communities surrounded by high LAI values have lower odds of being stunted (OR [odds ratio] = 0.63; 95% CI [confidence interval] = 0.47-0.86) than those exposed to low LAI values. The association still holds when the exposure is analysed as a continuous variable (OR = 0.84; 95% CI = 0.74-0.95).When stratified in rural and urban areas, a significant association was only observed in rural areas (OR = 0.6; 95% CI = 0.39-0.81), but not in urban areas (OR = 0.9; 95% CI = 0.5-0.5). Furthermore, the study showed that these associations were robust to LAI buffer variations under 25 km.

Conclusions

Good vegetation conditions have a protective effect against stunting in children under five years of age. Further advanced study designs are needed to confirm these findings.

Prevalence and correlates of reproductive coercion across ten sites: commonalities and divergence

BACKGROUND

Reproductive coercion (RC) is a type of abuse where a partner asserts control over a woman's reproductive health trajectories. Recent research emphasizes that RC experiences may differ within and across low- and middle-income countries (LMICs), as compared to higher income contexts, given social pressures surrounding childbearing. To date, nationally representative surveys have lacked comprehensive measures for RC, leading to gaps in understanding its prevalence and risk factors. Across eight LMICs (10 sites), we aimed to (1) validate the RC Scale; (2) calculate prevalence of RC and specific behaviors; and (3) assess correlates of RC.

METHODS

This analysis leverages cross-sectional Performance Monitoring for Action (PMA) data collected from November 2020 to May 2022. Analyses were limited to women in need of contraception (Burkina Faso n = 2767; Côte d'Ivoire n = 1561; Kongo Central, Democratic Republic of Congo (DRC) n = 830; Kinshasa, DRC n = 846; Kenya n = 4588; Kano, Nigeria n = 535; Lagos, Nigeria n = 612; Niger n = 1525; Rajasthan, India n = 3017; Uganda n = 2020). Past-year RC was assessed via five items adapted from the original RC Scale and previously tested in LMICs. Confirmatory factor analysis examined fit statistics by site. Per-item and overall prevalence were calculated. Site-specific bivariate and multivariable logistic regression examined RC correlates across the socioecological framework.

RESULTS

Confirmatory factor analysis confirmed goodness of fit across all sites, with moderate internal consistency (alpha range: 0.66 Cote d'Ivoire-0.89 Kinshasa, DRC/Lagos, Nigeria). Past-year reported prevalence of RC was highest in Kongo Central, DRC (20.3%) and lowest in Niger (3.1%). Prevalence of individual items varied substantially by geography. Polygyny was the most common RC risk factor across six sites (adjusted odds ratio (aOR) range: 1.59-10.76). Increased partner education levels were protective in Kenya and Kano, Nigeria (aOR range: 0.23-0.67). Other assessed correlates differed by site.

CONCLUSIONS

Understanding RC prevalence and behaviors is central to providing woman-centered reproductive care. RC was most strongly correlated with factors at the partner dyad level; future research is needed to unpack the relative contributions of relationship power dynamics versus cultural norms surrounding childbearing. Family planning services must recognize and respond to women's immediate needs to ensure RC does not alter reproductive trajectories, including vulnerability to unintended pregnancy.

Determinants of the use of contraceptive methods by adolescents in the Democratic Republic of the Congo: results of a cross-sectional survey

Background

Family planning (FP) is an effective strategy to prevent unintended pregnancies of adolescents. We aimed at identifying the socio-demographic factors underlying the low use of contraceptive methods by teenage girls in the Democratic Republic of the Congo (DRC).

Methods

A secondary analysis targeting teenage girls aged 15–19 was carried out on the Performance, Monitoring and Accountability project 2020 (PMA 2020) round 7 data, collected in Kinshasa and Kongo Central provinces. The dependent variable was the “use of contraceptive methods by sexually active teenage girls”, calculated as the proportion of teenagers using modern, traditional or any contraceptive methods. Independent variables were: level of education, age, province, religion, marital status, number of children, knowledge of contraceptive methods and household income. Pearson's chi-square and logistic regression tests helped to measure the relationship between variables at the alpha significance cut point of 0.05.

Results

A total of 943 teenagers were interviewed; of which 22.6, 18.1 and 19.9% ​​used any contraceptive method respectively in Kinshasa, Kongo Central and overall. The use of modern contraceptive methods was estimated at 9.9, 13.4 and 12.0% respectively in Kinshasa, Kongo Central and overall. However, the use of traditional methods estimated at 8.0% overall, was higher in Kinshasa (12.7%) and lower (4.7%) in Kongo Central (p < .001). Some factors such as poor knowledge of contraceptive methods (aOR = 8.868; 95% CI, 2.997–26.240; p < .001); belonging to low-income households (aOR = 1.797; 95% CI, 1.099–2.940; p = .020); and living in Kongo central (aOR = 3.170; 95% CI, 1.974–5.091; p < .001) made teenagers more likely not to use any contraceptive method.

Conclusion

The progress in the use of contraceptive methods by adolescent girls is not yet sufficient in the DRC. Socio-demographic factors, such as living in rural areas, poor knowledge of FP, and low-income are preventing teenagers from using FP methods. These findings highlight the need to fight against such barriers; and to make contraceptive services available, accessible, and affordable for teenagers.

Do users of long-acting reversible contraceptives receive the same counseling content as other modern method users? A cross-sectional, multi-country analysis of women's experiences with the Method Information Index in six sub-Saharan African countries

Objective

There has been a growing focus on informed choice in contraceptive research. Because removal of long-acting reversible contraception (LARC), including implants and IUDs, requires a trained provider, ensuring informed choice in the adoption of these methods is imperative. We sought to understand whether information received during contraceptive counseling differed among women using LARC and those using other modern methods of contraception.

Study Design

We used cross-sectional data from Burkina Faso, Côte d'Ivoire, the Democratic Republic of Congo (DRC), Kenya, Nigeria, and Uganda collected in 2019-2020 by the Performance Monitoring for Action project. We included 7969 reproductive-aged women who reported use of modern contraception. Our outcome of interest, information received during contraceptive counseling, was measured using a binary indicator of whether respondents answered "yes" to all 4 questions that make up the Method Information Index Plus (MII+). We used modified Poisson models to estimate the prevalence ratio between method type (LARC vs. other modern methods) and the MII+, controlling for individual- and facility-level covariates.

Results

Reported receipt of the full MII+ during contraceptive counseling ranged from 21% in the DRC to 51% in Kenya. In all countries, a higher proportion of LARC users received the MII+ compared to other modern method users. A greater proportion of LARC users answered "yes" to all questions that make up the MII+ at the time of counseling compared to other modern method users in DRC, Kenya, Nigeria, and Uganda. There was no significant difference in the prevalence of reporting the full MII+ between users of LARC and other modern methods in Burkina Faso (Adjusted prevalence ratio (aPR): 1.16; 95% confidence interval (CI): 0.91, 1.48) and Côte d'Ivoire (aPR: 1.13; 95% CI: 0.87, 1.45).

Conclusion

Information received during contraceptive counseling was limited for all modern contraceptive users. LARC users had significantly higher prevalence of receiving the MII+ compared to other modern method users in the DRC, Kenya, and Uganda. Family planning programs should ensure that all women receive complete, unbiased contraceptive counseling.

Implications

Across 6 sub-Saharan African countries, a substantial proportion reproductive-aged women using contraception did not report receiving comprehensive counseling when they received their method. Women using long-acting reversible contraception received more information compared to women using other modern methods in the DRC, Kenya, Nigeria, and Uganda after controlling for individual- and facility-level factors.

Determinants of Survival of HIV Patients Receiving Dolutegravir: A Prospective Cohort Study in Conflict-Affected Bunia, Democratic Republic of Congo

This study aims to determine the factors influencing HIV-related mortality in settings experiencing continuous armed conflict atrocities. In such settings, people living with HIV (PLHIV), and the partners of those affected may encounter specific difficulties regarding adherence to antiretroviral therapy (ART), and retention in HIV prevention, treatment, and care programs. Between July 2019 and July 2021, we conducted an observational prospective cohort study of 468 PLHIV patients treated with Dolutegravir at all the ART facilities in Bunia. The probability of death being the primary outcome, as a function of time of inclusion in the cohort, was determined using Kaplan-Meier plots. We used the log-rank test to compare survival curves and Cox proportional hazard modeling to determine mortality predictors from the baseline to 31 July 2021 (endpoint). The total number of person-months (p-m) was 3435, with a death rate of 6.70 per 1000 p-m. Compared with the 35-year-old reference group, older patients had a higher mortality risk. ART-naïve participants at the time of enrollment had a higher mortality risk than those already using ART. Patients with a high baseline viral load (≥1000 copies/mL) had a higher mortality risk compared with the reference group (adjusted hazard ratio = 6.04; 95% CI: 1.78-20.43). One-fourth of deaths in the cohort were direct victims of armed conflict, with an estimated excess death of 35.6%. Improving baseline viral load monitoring, starting ART early in individuals with high baseline viral loads, the proper tailoring of ART regimens and optimizing long-term ART, and care to manage non-AIDS-related chronic complications are recommended actions to reduce mortality. Not least, fostering women's inclusion, justice, peace, and security in conflict zones is critical in preventing premature deaths in the general population as well as among PLHIV.

The emergence of COVID-19 in the Democratic Republic of Congo: Community knowledge, attitudes, and practices in Kinshasa

Background

The first COVID-19 case in the Democratic Republic of Congo (DRC) was reported on 10 March 2020 in Kinshasa, prompting the government to promote internationally agreed non-pharmacological interventions for infection prevention and control. Public compliance to these measures is critical and depends on the knowledge, attitudes, and practices (KAP) of communities regarding COVID-19, for which there was no data. This study aimed to bridge that gap.

Methods

A community-based cross-sectional study was conducted in Kinshasa in June 2020, during the emergency state, following a four-stage sampling process. Master’s students from the Kinshasa School of Public Health conducted the survey. Descriptive and regression analyses were performed.

Results

The study enrolled 726 women and 600 men (mean age: 43; SD 16-85). Nearly everyone heard about COVID-19 (mainly through television, radio, and street reports), but only 17% were highly knowledgeable about its transmission modes, signs and symptoms, and preventive measures. More than 80% of participants believed in the disease’s seriousness; however, only 21% found the total lockdown acceptable. Nonetheless, 86% reported regular hand cleaning and mask-wearing followed by physical distancing (72%). Poorer, younger, and non-Catholic participants were overall markedly less knowledgeable and had comparatively lower levels of health-protective attitudes, acceptance, and practices. The education level and household size did not matter. Female participants tended to show fewer enabling attitudes and practices toward COVID-19 prevention measures compared to men.

Conclusion

Adequate public health information to improve the population’s KAP related to COVID-19 is critical and must be designed with and delivered to the community—considering the specific needs of diverse sub-groups and contexts. Studies in Kinshasa and similar settings are necessary to understand the barriers to and enablers of acquiring, applying, and maintaining the optimal population’s KAP for COVID-19 prevention and control.

Incidence and Predictors of Loss to Follow Up among Patients Living with HIV under Dolutegravir in Bunia, Democratic Republic of Congo: A Prospective Cohort Study

This study aimed to examine the incidence and predictors of loss to follow up (LTFU) in the context of ongoing atrocities caused by armed conflict, where HIV treatment programs and HIV-infected patients may face unique challenges in terms of ART adherence and retention in care. We conducted an observational prospective cohort study of 468 patients living with HIV (PLWHIV) under dolutegravir (DTG) in all health facilities in Bunia between July 2019 and July 2021. Kaplan-Meier plots were used to determine the probability of LTFU as a function of time as inclusive of the cohort. The main outcome variable was LTFU, defined as not taking an ART refill for a period of 3 months or longer from the last attendance for refill, and not yet classified as 'dead' or 'transferred-out.' The log-rank test was used to compare survival curves based on predictors. Cox proportional hazard modeling was used to measure predictors of LTFU from the baseline until 31 July 2021 (the endpoint). A total of 3435.22 person-months (p-m) were involved in follow up, with an overall incidence rate of 33.48 LTFU per 1000 p-m. Patients who had less experience with ART at enrolment and the ethnically Sudanese, had a higher hazard of being LTFU compared to their reference groups. This study reports a high LTFU rate in this conflict setting. An ART program in such a setting should pay more attention to naive patients and other particularly vulnerable patients such as Sudanese during the pre-ART phase. The study implies the implementation of innovative strategies to address this high risk of being LTFU, reducing either the cost or the distance to the health facility.

Understanding the Broader Impacts of COVID-19 on Women and Girls in the DRC through Integrated Outbreak Analytics to Reinforce Evidence for Rapid Operational Decision-Making

Whilst men and boys account for more COVID-19 cases and deaths, the secondary impacts of the outbreak on women and girls in the Democratic Republic of the Congo are cross-cutting and far-reaching. School closures put girls at increased risk of adolescent pregnancy, sexual violence and early marriage; more women working in the informal sector have lost jobs and been affected by closures of markets and borders; and frequent restrictions on sexual and reproductive healthcare have impacted access to services for women. Lessons learnt from previous health crises can help to highlight the extent of these issues. However, a lack of sex disaggregated data around COVID-19 morbidity and mortality in the DRC means that it is impossible to fully measure and understand the impact of the outbreak on women and girls or develop and implement appropriate interventions. This article presents a metasynthesis of existing and ongoing analyses to highlight the broader impacts of COVID-19 on women and girls in the country.

Biennial surveillance of Plasmodium falciparum anti-malarial drug resistance markers in Democratic Republic of Congo, 2017 and 2019

Background

Because of the loss of chloroquine (CQ) effectiveness, the Democratic Republic of Congo (DRC)’s malaria treatment policy replaced CQ by sulfadoxine–pyrimethamine (SP) as first-line treatment of uncomplicated malaria in 2003, which in turn was replaced by artemisinin-based combination therapies (ACT) in 2005. The World Health Organization (WHO) recommends monitoring of anti-malarial drug resistance every 2 years. The study aimed to provide baseline data for biennial molecular surveillance of anti-malarial drug resistance by comparing data from a study conducted in 2019 to previously published data from a similar study conducted in 2017 in the DRC.

Methods

From July to November 2019, a cross-sectional study was conducted in ten sites which were previously selected for a similar study conducted in 2017 across the DRC. P. falciparum malaria was diagnosed by a rapid diagnostic test (RDT) or by microscopy and dried blood samples (DBS) were taken from patients who had a positive test. Segments of interest in pfcrt and pfk13 genes were amplified by conventional PCR before sequencing.

Results

Out of 1087 enrolled patients, 906 (83.3%) were PCR-confirmed for P. falciparum. Like in the 2017-study, none of the mutations known to be associated with Artemisinine (ART) resistance in Southeast Asia was detected. However, non-synonymous (NS) mutations with unknown functions were observed among which, A578S was detected in both 2017 and 2019-studies. The overall prevalence of pfcrt-K76T mutation that confers CQ-resistance was 22.7% in 2019-study compared to 28.5% in 2017-study (p-value = 0.069), but there was high variability between sites in the two studies. Like in 2017-study, the pfcrt 72–76 SVMNT haplotype associated with resistance to amodiaquine was not detected.

Conclusion

The study reported, within 2 years, the non-presence of molecular markers currently known to be associated with resistance to ART and to AQ in P. falciparum isolated in the DRC. However, the presence of polymorphisms with as-yet unknown functions was observed, requiring further characterization. Moreover, an overall decrease in the prevalence of CQ-resistance marker was observed in the DRC, but this prevalence remained highly variable from region to region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07112-z.

As long as (I think) my husband agrees…: role of perceived partner approval in contraceptive use among couples living in military camps in Kinshasa, DRC

BACKGROUND

Male partner's approval is a key determinant of contraceptive use for women living in Sub-Saharan Africa and improving men's support and couple communication is a cornerstone of family planning programs. However, approval is often only measured through the women's perception of their partner's opinion.

METHODS

This study conducted in Kinshasa compares contraceptive approval variables from matched male and female partners (n = 252 couples) to establish the frequency of (in)accurate perceptions by the woman, then test their association with modern contraceptive use. Additional regressions estimate individual and couple variables associated with (in)correct perceptions.

RESULTS

Results confirm women are poorly aware of their partner's opinion but indicate that perceived approval or disapproval by the woman is a much stronger determinant of modern contraceptive use than her partner's actual opinion. Higher educational achievement from the woman is the strongest driver of misunderstanding her partner's approval.

CONCLUSIONS

Women's perceptions of partner's approval are much stronger determinant of contraceptive use than the latter's actual opinion, and stereotyping men's opinion of family planning is a common error of appreciation. However, findings also suggest these misunderstandings might serve women's capacity to negotiate contraceptive use.

Factors influencing client recall of contraceptive counseling at community-based distribution events in Kinshasa, Democratic Republic of the Congo

BACKGROUND

Clients must recall information from contraceptive counseling sessions to properly use their chosen method. Client recall in community-based settings is challenging given the public nature of these events and the presence of many potential distractions. Understanding the factors that influence client recall during community-based distribution events can guide future training of providers to improve proper use of contraceptive methods and client satisfaction.

METHODS

This cross-sectional study employed a convenience sample of 957 women ages 15-49 old who sought contraceptive services from community-based contraceptive distribution events in Kinshasa, Democratic Republic of the Congo, known as Lelo PF. Recall scores were developed by matching direct observations with client exit interviews. The association between recall and client characteristics, provider characteristics and an index for the quality of the provider-client interaction were tested using multivariate linear regression.

RESULTS

The average recall score was 67.6%. Recall scores were higher among clients who accepted methods with simpler administration procedures, such as CycleBeads (81.3%), compared to methods requiring more medically advanced administration procedures, such as DMPA-SC (56.6%) and Implanon-NXT (62.1%). This relationship held even after controlling for amount of information each client received. Status as a first-time user was associated with a 5.8 percentage point decrease in recall score (p = 0.002). Time since the provider's initial family planning training and clients' perception of the provider-client interaction were associated with higher client recall scores.

CONCLUSION

Results of this study suggest that to improve client recall at Lelo PF events, future provider training should focus on how to deliver clear, specific information to clients, making sure clients feel at ease during the counseling session, and treating clients with respect. First-time family planning users and clients who select methods with more medically advanced administration procedures may require extra attention during the consultation to ensure they are able understand and remember the information. Results suggest that providers who have been offering services longer may be more effective in conveying information in a way that clients can remember. Program managers should consider requesting input from experienced providers to improve training sessions.

The gap in contraceptive knowledge and use between the military and non-military populations of Kinshasa, DRC, 2016-2019

Introduction

The objective of this study is to assess change over time in the modern contraceptive prevalence rate (MCPR) and related variables among married women of reproductive age (15–49 years) in the military population in Kinshasa, Democratic Republic of Congo, compared to women in the non-military population, based on cross-sectional surveys in 2016 and 2019.

Methods

Data among women living in military camps were collected as a special study of contraceptive knowledge, use, and exposure to FP messaging, for comparison to women in the non-military population from the annual PMA2020 survey. Both used a two-stage cluster sampling design to randomly select participants. This analysis is limited to women married or in union. Bivariate and multivariate analysis was used to compare the military and non-military populations.

Results

The socio-demographic profile of women in the military camps differed between 2016 and 2019, which may reflect the more mobile nature of this population. In both populations, knowledge of modern contraceptive methods increased significantly. Similarly, use of a modern contraceptive method also increased significantly in both, though by 2019 women in the military camps were less likely to use modern contraception (24.9%) than their non-military counterparts (29.7%). Multivariate analysis showed no significant difference in the amount of increase in MCPR for the two populations. Among contraceptive users in both populations, the implant was the leading method. Potential effects of FP programming were evident in the military population: exposure to FP messaging increased (in comparison to a decrease among the non-military population). Moreover, women who had lived in the camps for 4+ years had a higher MCPR than those living in the camps for less than four years.

Conclusions

This study demonstrates the feasibility and importance of collecting data in military camps for better understanding contraceptive dynamics among this specialized population.

Micronutrient intake and prevalence of micronutrient inadequacy among women (15-49 y) and children (6-59 mo) in South Kivu and Kongo Central, Democratic Republic of the Congo (DRC)

Iron biofortified beans and carotenoid enriched cassava are proposed as a solution to combat iron and vitamin A deficiencies, respectively, in the Democratic Republic of Congo (DRC). To inform the need for biofortified foods, we conducted a survey in 2014 in two provinces of the DRC, South Kivu and Kongo Central. Unexpectedly, women of reproductive age (WRA; 15-49 y) and their children (6-59 m) had a low prevalence of biochemical iron and vitamin A deficiency, based on ferritin and retinol binding protein, respectively. To better understand the lack of biochemical deficiency of these nutrients, we examined the prevalence of inadequate intake for these and other select nutrients. Dietary intake was assessed using 24-hour recalls among 744 mother-child dyads. Repeat recalls on a non-consecutive day were conducted with a subsample of the study population to account for intra-individual variation and estimate usual intake. In WRA, the prevalence of inadequate iron intakes were 33% and 29% in South Kivu and Kongo Central, respecitvely. The prevalence of inadequate vitamin A intakes among WRA was low in South Kivu (18%) and negligible in Kongo Central (1%). Iron inadequacy was highest in infants (6-11 m) at 82% and 64% in South Kivu and Kongo Central, respectively. Among older children (12-59 m) in both provinces, the prevalence of iron inadequacy was similar at ~20%. There was a high prevalence of inadequate zinc intake in women and children (i.e. 79-86% among WRA and 56-91% among children 6-59 m) consistent with our findings of a high prevalence of low serum zinc in the same sample. Dietary data here corroborate the low prevalence of biochemical vitamin A deficiency but not iron. However, any change to the supply of red palm oil (primary source of vitamin A) would dramatically reduce population vitamin A intakes, thus a carotenoid enriched cassava program may be beneficial as a safety net measure. Crops biofortified with zinc also appear warranted. We caution that our findings cannot be extrapolated to the entire Congo where diverse agro-ecological landscape exist or when political and environmental shocks occur which challenge food production.

Evolution of a Large-Scale Community-Based Contraceptive Distribution Program in Kinshasa, DRC Based on Process Evaluation

Midterm process evaluation results indicated that design and implementation failures hindered the program's success, notably: (1) the short-acting methods provided by community-based distributors (CBDs) offered limited choice; (2) the nominal revenue retained from selling the methods provided limited motivation for the volunteer CBDs; and (3) the model was poorly coordinated with the existing clinical service system, partly because of challenging systems issues. In the revised model, the CBDs will also provide subcutaneous injectables and emergency contraceptive pills, retain more revenue from contraceptive sales, and have better interaction with the existing system including conducting monthly mini-campaigns to increase visibility and attract more clients.

In a context where distance, user fees, and health staff shortages constitute significant barriers to accessing facility-based family planning services, the use of community-based distributors (CBDs) as counseling and contraceptive providers has been tested in several resource-constrained environments to increase family planning uptake. In the capital city of the Democratic Republic of the Congo (DRC), Kinshasa, a massive CBD program (AcQual) has been implemented since 2014, with lackluster results measured in terms of the low volume of contraceptives provided. A process evaluation conducted in 2017 assessed the fidelity of implementation of the program compared with the original AcQual design and analyzed gaps in provider training and motivation, contraceptive supplies, and reporting and monitoring processes. Its objective was to identify both theory and implementation failures in order to propose midcourse corrections for the program. The mixed-method data collection focused on the CBDs as a pivotal component of the AcQual program with 700 active CBDs interviewed. In addition, 10 in-depth interviews were conducted with clinical personnel, local health program managers, and project partners to identify gaps in the AcQual implementation environment. Issues with CBDs' performance, knowledge retention, and commitment to program activities, as well as gaps in contraceptive supply chains and insufficient monitoring and supervision processes, were the main implementation failures identified. Inappropriate method mix offered by the CBDs (condoms, pills, and CycleBeads only) and chronic overburdening of health care staff at the local level compounded these issues and explained the low volume of contraceptives provided through AcQual. Midcourse corrections included a more structured schedule of activities, stronger integration of CBDs with clinical providers and health zone managers, expansion of the mix of contraceptives offered to include subcutaneous injectables and emergency contraceptive pills, and clarifying reporting and monitoring responsibilities among all partners. Findings from this process evaluation contribute to the limited knowledge base regarding “unwelcome results” by examining all the intervention components and their relationships to highlight areas of potential failures, both in design and implementation, for similar CBD programs.

Serum Soluble Transferrin Receptor Concentrations Are Elevated in Congolese Children with Glucose-6-Phosphate Dehydrogenase Variants, but Not Sickle Cell Variants or α-Thalassemia

Background: Anemia is common in Congolese children, and inherited blood disorders may be a contributing cause. The presence of sickle cell variants, X-linked glucose-6-phosphate dehydrogenase (G6PD) deficiency and α-thalassemia, has been previously reported. G6PD A- deficiency is characterized by the co-inheritance of G6PD 376 and 202 variants and is common in sub-Saharan Africa.Objective: We aimed to measure the associations between inherited blood disorders and hemoglobin, ferritin, and soluble transferrin receptor (sTfR) concentrations in Congolese children.Methods: Venous blood was collected from 744 children aged 6-59 mo from 2 provinces. We measured biomarkers of nutritional and inflammation status and malaria. Pyrosequencing was used to detect sickle cell variants. Polymerase chain reaction was used to detect G6PD variants and α-thalassemia deletions.Results: Overall, 11% of children had a sickle cell variant, 19% of boys were G6PD A- hemizygotes, 12% and 10% of girls were G6PD A- hetero- or homozygotes, respectively, and 12% of children had α-thalassemia. Multivariable linear regression models (adjusted for age, province, altitude, malaria, and biomarkers of nutritional and inflammation status) showed that G6PD A- hemizygous boys and G6PD 376 homozygous girls had higher sTfR concentrations [geometric mean ratios (95% CIs): 1.20 (1.03, 1.39) and 1.25 (1.02, 1.53), respectively] than children with no G6PD variants. Hemoglobin and ferritin concentrations were not independently associated with any of the inherited blood disorder genotypes.Conclusions: We found that 2 G6PD variant genotypes were associated with elevated sTfR concentrations, which limits the accuracy of sTfR as a biomarker of iron status in this population.

The effect of inflammation on serum zinc concentrations and the prevalence estimates of population-level zinc status among Congolese children aged 6-59 months

BACKGROUND/OBJECTIVES

Zinc is a negative acute-phase reactant; hence, its concentration decreases in the presence of inflammation. There is no current consensus on how to control for the effect of inflammation on serum zinc, which has implications for accurate estimates of population-level zinc status. We aimed to measure the association between inflammation and serum zinc concentrations and to compare the means and the prevalence of zinc deficiency using unadjusted and inflammation-adjusted serum zinc concentrations among Congolese children.

SUBJECTS/METHODS

Non-fasting blood was collected in the afternoon in trace element-free vacutainers from 744 apparently healthy children aged 6-59 months in the Democratic Republic of the Congo. Serum was analyzed for zinc, C-reactive protein (CRP) and α-1 acid glycoprotein (AGP) for 665 children with complete data for all three biomarkers. Linear regression was used to generate correction factors (CFs) based on three stages of inflammation: incubation (CRP >5 mg/l and normal AGP), early convalescence (CRP >5 mg/l and AGP >1 g/l) and late convalescence (AGP >1 g/l and normal CRP), relative to no inflammation.

RESULTS

Overall unadjusted mean±s.d. serum zinc concentration was 9.4±2.1 μmol/l. Study-generated CFs (95% confidence interval) for incubation, early and late convalescence were 1.01 (0.88, 1.14), 1.15 (1.11, 1.21) and 1.07 (1.03, 1.11), respectively. After applying the CFs, overall adjusted mean±s.d. serum zinc concentration was 10.1±2.2 μmol/l, and prevalence of zinc deficiency (<8.7 μmol/l) decreased from 35% (n=234/665) to 24% (n=160/665).

CONCLUSIONS

Adjustment of zinc concentrations for inflammation is warranted when assessing population-level zinc status.European Journal of Clinical Nutrition advance online publication, 23 August 2017; doi:10.1038/ejcn.2017.127.

Clinical phenotypes and the biological parameters of Congolese patients suffering from sickle cell anemia: A first report from Central Africa

BACKGROUND

The influence of phenotype on the clinical course and laboratory features of sickle cell anemia (SCA) is rarely described in sub-Saharan Africa.

METHODS

A cross-sectional study was conducted in Kinshasa. A clinical phenotype score was built up. The following definitions were applied: asymptomatic clinical phenotype (ACP; score≤5), moderate clinical phenotype (MCP; score between 6 and 15), and severe clinical phenotype (SCP; score≥16). ANOVA test were used to compare differences among categorical variables.

RESULTS

We have studied 140 patients. The mean body mass index (BMI) value of three groups was lower (<25 kg/m² ) than the limit defining overweight. BMI of the subjects with ACP was significantly higher than those of other phenotypes (P<.05). Sickle cell patients with ACP have a high mean steady-state hemoglobin concentration compared to those with MCP and SCP (P<.001). A significant elevated baseline leukocyte count is associated with SCP (P<.001). Fetal Hemoglobin (HbF) was significantly higher in ACP. Significant elevation of alpha 1 and alpha 2 globulins in SCP were observed.

CONCLUSION

In our study, fetal hemoglobin has an influence on the clinical severity and the biological parameters of SCA. The study provides data concerning the sickle cell anemia clinical and biological variability in our midst.

Albuminuria, serum antioxidant enzyme levels and markers of hemolysis and inflammation in steady state children with sickle cell anemia

BACKGROUND

Oxidative stress is thought to be involved in the pathogenesis of microalbuminuria in Sickle cell anemia (SCA). Antioxidant enzymes such as glutathione peroxidase (GPx) and Cu-Zn superoxide dismutase (SOD) may play an important protective role. This study aimed to evaluate the association between albuminuria and these two antioxidant enzymes.

METHODS

We consecutively recruited Steady state children aged between 2 and 18 years old with established diagnosis of homozygous SCA in two hospitals of Kinshasa/DR Congo. The relationship between Urinary Albumin Creatinine Ratio (UACR) and other variables of interest (age, systolic blood pressure, diastolic blood pressure, plasma GPx and Cu-Zn SOD, free plasmatic hemoglobin, LDH, indirect bilirubin, white blood cells (WBC), percentage of fetal hemoglobin, serum iron, ferritin, CRP) was analyzed by Bivariate correlation (Pearson's correlation coefficient). Microalbuminuria was defined by urine albumin/creatinine ratio between 30 and 299 mg/g.

RESULTS

Seventy Steady state Black African children with SCA (56% boys; average age 9.9 ± 4.3 years; 53% receiving hydroxyurea) were selected. Prevalence of microalbuminuria was 11.8%. LDH (r = 0.260; p = 0.033) and WBC count (r = 0.264; p = 0.033) were positively correlated with UACR whereas GPx (- 0.328; p = 0.007) and Cu-Zn SOD (- 0.210; p = 0.091) were negatively correlated with UACR.

CONCLUSIONS

Albuminuria is associated with decreased antioxidant capacity and increased levels of markers of hemolysis and inflammation. Therefore, strategies targeting the reduction of sickling and subsequent hemolysis, oxidative stress and inflammation could help preventing or at least delaying the progression of kidney disease in SCA children.

Anemia and Micronutrient Status of Women of Childbearing Age and Children 6-59 Months in the Democratic Republic of the Congo

Little is known about the micronutrient status of women and children in the Democratic Republic of the Congo, which is critical for the design of effective nutrition interventions. We recruited 744 mother-child pairs from South Kivu (SK) and Kongo Central (KC). We determined hemoglobin (Hb), serum zinc, vitamin B12, folate, ferritin, soluble transferrin receptor (sTfR), retinol binding protein (RBP), C-reactive protein, and α-1 acid glycoprotein concentrations. Anemia prevalence was determined using Hb adjusted for altitude alone and Hb adjusted for both altitude and ethnicity. Anemia prevalence was lower after Hb adjustment for altitude and ethnicity, compared to only altitude, among women (6% vs. 17% in SK; 10% vs. 32% in KC), children 6–23 months (26% vs. 59% in SK; 25% vs. 42% in KC), and children 24–59 months (14% vs. 35% in SK; 23% vs. 44% in KC), respectively. Iron deficiency was seemingly higher with sTfR as compared to inflammation-adjusted ferritin among women (18% vs. 4% in SK; 21% vs. 5% in KC), children 6–23 months (51% vs. 14% in SK; 74% vs. 10% in KC), and children 24–59 months (23% vs. 4% in SK; 58% vs. 1% in KC). Regardless of indicator, iron deficiency anemia (IDA) never exceeded 3% in women. In children, IDA reached almost 20% when sTfR was used but was only 10% with ferritin. Folate, B12, and vitamin A (RBP) deficiencies were all very low (<5%); RBP was 10% in children. The prevalence of anemia was unexpectedly low. Inflammation-adjusted zinc deficiency was high among women (52% in SK; 58% in KC), children 6–23 months (23% in SK; 20% in KC), and children 24–59 months (25% in SK; 27% in KC). The rate of biochemical zinc deficiency among Congolese women and children requires attention.

[Therapeutic outcomes of anti-tuberculosis treatment in the context of HIV-tuberculosis co-infection: Cohort of Kabinda Center in Kinshasa, Democratic Republic of Congo]

BACKGROUND

The study aimed to determine the clinical forms of tuberculosis and therapeutic outcome of anti-tuberculosis treatment in the context of HIV-tuberculosis co-infection.

METHODS

A retrospective cohort of 120 HIV-positive patients with tuberculosis and 297 HIV-negative patients with tuberculosis attending the Kabinda Center was followed from 2010 to June, 30th 2013. The logistic regression model identified the determinants of a defavorable outcome after initiation of tuberculostatics.

RESULTS

The proportion of female patients was higher in the co-infected group compared with the non-co-infected group (60.8% versus 42.7%, P<0.001). HIV-seropositive patients had more forms of pulmonary smear-negative (39.2% versus 25.3%, P<0.002) and extra-pulmonary (38% versus 35%, P<0.002) tuberculosis than HIV-negative patients. HIV-positive serology (OR: 3.13, 95%CI: 1.72-5.69) and age of patients more than 41 years (OR: 3.15, 95%CI: 1.36-7.29) were associated with an unfavorable outcome.

CONCLUSION

This study highlights the usefulness of a systematically determining immunological status in co-infected patients and a timely and systematic ARV treatment, together with early diagnosis of tuberculosis. It also emphasizes the importance of adherence to support measures in order to improve tuberculosis treatment outcomes in co-infected patients.

[Predictors of cesarean delivery in the Kinkanda general hospital in Matadi (Democratic Republic of Congo)]

OBJECTIVE

To identify predictors of cesarean delivery in the Kinkanda general hospital.

METHOD

Cross-sectional study conducted from 1st January 2012 to 31st December 2012, on women in labor who delivered at the maternity of Kinkanda. Predictors of cesarean delivery were identified by using binary logistic regression.

RESULTS

A uterine height of at least 33 cm at induction of labor (AOR 3.93 95% CI 2.04 to 7.59; p <0.001), primiparity (AOR 2.1 95%CI:1.06 to 4.15; p = 0.033), non-membership of the pregnant woman to this particular health center area (AOR 4.26 95%CI 2.16 to 8.42; p <0.001) and a weight of the newborn of at least 4000g (AOR 7.8 95%CI 2.3 to 26.44; p <0.001) were identified as risk factors for cesarean delivery.

CONCLUSION

Primiparity, uterine height of at least 33 cm, living in another health area than the Matadi area and fetal macrosomia are the main predictors of cesarean delivery during the year 2012 at the Kinkanda general hospital.

[Determinants of perinatal mortality in premature newborns in university clinics in Kinshasa]

BACKGROUND

Neonatal mortality is a sensitive indicator of the availability, use and effectiveness of obstetric and neonatal care. Prematurity is the leading cause of death in the neonatal period. In the DRC, prematurity remains a major public health problem. The objective of this study was to identify determinants of perinatal mortality premature to university clinics in Kinshasa.

METHODS

This was a cross-sectional study involving 192 preterm infants to university clinics in Kinshasa from January 2009 to December 2011. Perinatal mortality premature to university clinics was estimated and logistic regression was used to identify the determinants.

RESULTS

During the study period, premature mortality was 15.2% (95% CI 9.7 to 20.7). Determinants of perinatal mortality were: the birth weight of less than 1500g (OR: 5.66, 95% CI 1.87 to 17.1, p = 0.002) and gestational age. The premature 28 to 31 were more likely to die prematurely compared to 34 to 36 weeks gestation (OR 5.58, 95% CI: 1.23 to 25.3, p = 0.026) as well as premature of 32 to 33 were more likely to die prematurely compared to 34 to 36 weeks gestation (OR 6.46, 95% CI: 1.55 to 26.9, p = 0.01).

CONCLUSION

Given its status as the tertiary level, a strengthening of technical support university clinics in Kinshasa is of prime importance for the care of premature infants, especially prématurisim and those with less than 1500 g.