A scoping review to explore the understanding of Health Systems Resilience across three Caribbean countries, Saint Lucia, Dominica, and Haiti. The protocol.”

Background: The COVID-19 pandemic offers a window of opportunity for building resilient health systems. As such, it is important to use this opportunity to redesign, strengthen, and adapt health systems to meet current population needs. Health systems resilience (HSR) is even more critical in Caribbean countries which face health, environmental, economic shocks and in certain cases political and social upheavals. This study aims to explore the extent to which Haiti, Dominica, and Saint Lucia have developed HSR into their respective contexts.Methods: It will consist of a scoping review of available literature on HSR and/or health systems strengthening (HSS) covering Saint Lucia, Dominica, and Haiti, from 2010 to 2023. It will follow the five-point methodological framework proposed by Arksey and O'Malley (2005) and will answer the following question. What approaches, strategies or interventions contribute to building or strengthening HSR in dealing with shocks across these three countries? The perspectives, concepts, dimensions, and definitions from relevant scientific literature will be combined to generate the research equations. The papers identified via PubMed, Scopus, ProQuest, Google Scholar and OpenGrey will then be processed on EndNote and independently filtered by two researchers, reinforced by a third researcher in case of disagreement, according to the PRISMA method adjusted to scoping reviews. Following a deductive-inductive method, the material will be analysed thematically to identify the key approaches, strategies and interventions outlined in the retained materials.Results: This scoping review intends to produce a preliminary assessment of how HSR is implemented in the three participating countries. It holds the potential to shed new light on the experiences of these three countries in their efforts to attain resilience in their health systemsConclusions: This study might offer insight into the role of stakeholders and processes activated for the achievement of HSR in the Caribbean. In addition, it provides the starting point for the development of a tool to understand and realise HSR, tailored to the three countries.info:eu-repo/semantics/nonPublishe

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

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

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

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

Are people most in need utilising health facilities in post-conflict settings? A cross-sectional study from South Kivu, eastern DR Congo

Background: The disruptive effect of protracted socio-political instability and conflict on thehealth systems is likely to exacerbate inequities in health service utilisation in conflict-recovering contexts.Objective: To examine whether the level of healthcare need is associated with health facilityutilisation in post-conflict settings.Methods: We conducted a cross-sectional study among adults with diabetes, hypertension,mothers of infants with acute malnutrition, informal caregivers (of participants with diabetesand hypertension) and helpers of mothers of children acutely malnourished, and randomlyselected neighbours in South Kivu province, eastern DR Congo. Healthcare need levels werederived from a combination, summary and categorisation of the World Health OrganisationDisability Assessment Schedule 2.0. Health facility utilisation was defined as having utilised inthe first resort a health post, a health centre or a hospital as opposed to self-medication,traditional herbs or prayer homes during illness in the past 30 days. We used mixed-effectsPoisson regression models with robust variance to identify the factors associated with healthfacility utilisation.Results: Overall, 82% (n = 413) of the participants (N = 504) utilised modern health facilities.Health facility utilisation likelihood was higher by 27% [adjusted prevalence ratio (aPR): 1.27;95% CI: 1.13–1.43;p< 0.001] and 18% (aPR: 1.18; 95% CI: 1.06–1.30;p= 0.002) amongparticipants with middle and higher health needs, respectively, compared to those with lowhealthcare needs. Using the lowest health need cluster as a reference, participants in themiddle healthcare need cluster tended to have a higher hospital utilisation level.Conclusion: Greater reported healthcare need was significantly associated with health facilityutilisation. Primary healthcare facilities were the first resort for a vast majority of respondents.Improving the availability and quality of health service packages at the primary healthcarelevel is necessary to ensure the universal health coverage goal advocating quality health forall can be achieved in post-conflict settin

Understanding context of violence against healthcare through citizen science and evaluating the effectiveness of a co-designed code of conduct and of a tailored de-escalation of violence training in Eastern Democratic Republic of Congo and Iraq: a study protocol for a stepped wedge randomized controlled trial

Abstract Background Violence against health care workers (HCWs) is a multifaceted issue entwined with broader social, cultural, and economic contexts. While it is a global phenomenon, in crisis settings, HCWs are exposed to exceptionally high rates of violence. We hypothesize that the implementation of a training on de-escalation of violence and of a code of conduct informed through participatory citizen science research would reduce the incidence and severity of episodes of violence in primary healthcare settings of rural Democratic Republic of Congo (DRC) and large hospitals in Baghdad, Iraq. Methods In an initial formative research phase, the study will use a transdisciplinary citizen science approach to inform the re-adaptation of a violence de-escalation training for HCWs and the content of a code of conduct for both HCWs and clients. Qualitative and citizen science methods will explore motivations, causes, and contributing factors that lead to violence against HCWs. Preliminary findings will inform participatory meetings aimed at co-developing local rules of conduct through in-depth discussion and input from various stakeholders, followed by a validation and legitimization process. The effectiveness of the two interventions will be evaluated through a stepped-wedge randomized-cluster trial (SW-RCT) design with 11 arms, measuring the frequency and severity of violence, as well as secondary outcomes such as post-traumatic stress disorder (PTSD), job burnout, empathy, or HCWs’ quality of life at various points in time, alongside a cost-effectiveness study comparing the two strategies. Discussion Violence against HCWs is a global issue, and it can be particularly severe in humanitarian contexts. However, there is limited evidence on effective and affordable approaches to address this problem. Understanding the context of community distrust and motivation for violence against HCWs will be critical for developing effective, tailored, and culturally appropriate responses, including a training on violence de-escalation and a community behavioral change approach to increase public trust in HCWs. This study aims therefore to compare the effectiveness and cost-effectiveness of different interventions to reduce violence against HCWs in two post-crisis settings, providing valuable evidence for future efforts to address this issue. Trial registration ClinicalTrial.gov Identifier NCT05419687. Prospectively registered on June 15, 2022

Adaptive Mechanisms of Health Zones to Chronic Traumatics Events in Eastern DRC: A Multiple Case Study

BackgroundThe Eastern part of the Democratic Republic of Congo (DRC) has been affected by armed conflict for several years. Despite the growing interest in the impact of these conflicts on health service utilisation, few studies have addressed the coping mechanisms of the health system. The purpose of this study is to describe the traumatic events and coping mechanisms used by the health zones (HZs) in conflict settings to maintain good performance.MethodsThis multiple case study took place from July to October 2022 in four HZs in the South Kivu Province of DRC. HZs were classified into "cases" according to their conflict profile: accessible and stable (Case 1), accessible but remote (Case 2), unstable (Case 3), and intermediate (Case 4). Eight performance indicators and the amount of funding provided to the HZs by non-governmental organizations (NGOs) were recorded. A graph was created to compare their evolution from 2013 to 2018. A thematic analysis of qualitative data from individual interviews with selected health workers was conducted.ResultsBoth battle-related events (war and its effects) and non-battle-related events (epidemics, disasters, strikes) were recorded according to the case conflict-profile. Although the cases (3 and 4) most affected by armed conflicts occasionally performed better than the stable ones (1 and 2), their operational action plan was poorly carried out. The coping mechanisms developed in cases 3 and 4 were the deployment of military nurses in preventive and supervisory activities, the solicitations of subsidies from NGOs, the relocation of health care facilities and the implementation of negotiation strategies with the belligerents.ConclusionArmed conflict results in traumatic events that disrupt the execution of the operational action plan of HZs. The HZs' management team expertise, its strong leadership, and substantial financial support would enable this system to develop reliable and sustainable adaptive mechanisms.info:eu-repo/semantics/publishe

Adaptive Mechanisms of Health Zones to Chronic Traumatics Events in Eastern DRC: A Mul-tiple Case Study

Background: The Eastern part of the Democratic Republic of Congo (DRC) has been affected by armed conflict for several years. Despite the growing interest in the impact of these conflicts on health service utilisation, few studies have addressed the coping mechanisms of the health system. The purpose of this study is to describe the traumatic events and coping mechanisms used by the health zones (HZs) in conflict settings to maintain good performance.Methods: This multiple case study took place from July to October 2022 in four HZs in the South Kivu Province of DRC. HZs were classified into "cases" according to their conflict profile: accessible and stable (Case 1), accessible but remote (Case 2), unstable (Case 3), and intermediate (Case 4). Eight performance indicators and the amount of funding provided to the HZs by non-governmental organizations (NGOs) were recorded. A graph was created to compare their evolution from 2013 to 2018. A thematic analysis of qualitative data from individual interviews with selected health workers was conducted.Results: Both battle-related events (war and its effects) and non-battle-related events (epidemics, disasters, strikes) were recorded according to the case conflict-profile. Although the cases (3 and 4) most affected by armed conflicts occasionally performed better than the stable ones (1 and 2), their operational action plan was poorly carried out. The coping mechanisms developed in cases 3 and 4 were the deployment of military nurses in preventive and supervisory activities, the solicitations of subsidies from NGOs, the relocation of health care facilities and the implementation of negotiation strategies with the belligerents.Conclusion: Armed conflict results in traumatic events that disrupt the execution of the operational action plan of HZs. The HZs’ management team expertise, its strong leadership, and substantial financial support would enable this system to develop reliable and sustainable adaptive mechanisms.info:eu-repo/semantics/publishe

Comparative analysis of the health status of the population in six health zones in South Kivu: a cross-sectional population study using the WHODAS.

The eastern Democratic Republic of Congo (DRC) has experienced decades-long armed conflicts which have had a negative impact on population's health. Most research in public health explores measures that focus on a specific health problem rather than overall population health status. The aim of this study was to assess the health status of the population and its predictors in conflict settings of South Kivu province, using the World Health Organization Disability Assessment Schedule (WHODAS). Between May and June 2019, we conducted a community-based cross-sectional survey among 1440 adults in six health zones (HZ), classified according to their level of armed conflict intensity and chronicity in four types (accessible and stable, remote and stable, intermediate and unstable). The data were collected by a questionnaire including socio-demographic data and the WHODAS 2.0 tool with 12 items. The main variable of the study was the WHODAS summary score measuring individual's health status and synthesize in six domains of disability (household, cognitive, mobility, self-care, social and society). Univariate analysis, correlation and comparison tests as well as hierarchical multiple linear regression were performed. The median WHODAS score in the accessible and stable (AS), remote and stable (RS), intermediate (I) and unstable (U) HZ was 6.3 (0-28.6); 25 (6.3-41.7); 22.9 (12.5-33.3) and 39.6 (22.9-54.2), respectively. Four of the six WHODAS domain scores (household, cognitive, mobility and society) were the most altered in the UHZs. The RSHZ and IHZ had statistically comparable global WHODAS scores. The stable HZs (accessible and remote) had statistically lower scores than the UHZ on all items. In regression analysis, the factors significantly associated with an overall poor health status (or higher WHODAS score) were advanced age, being woman, being membership of an association; being divorced, separated or widower and living in an unstable HZ. Armed conflicts have a significantly negative impact on people's perceived health, particularly in crisis health zones. In this area, we must accentuate actions aiming to strengthen people's psychosocial well-being

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

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