Association between diagnostic criteria for severe acute malnutrition and hospital mortality in children aged 6-59 months in th eastern Democratic Republic of Congo: the Lwiro cohort study

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Malnutrition durant l’enfance, maladie chronique, capital humain à l’âge adulte dans le contexte de l’Est de la République Démocratique du Congo (Sud-Kivu)

Introduction :Les pays à bas et moyens revenus (PBMR) traversent une phase de transition nutritionnelle qui s’accompagne d’un accroissement rapide des pathologies cardio-métaboliques et de leurs facteurs de risque, à l’instar de l’obésité chez l’adulte, alors que la sous-nutrition prédomine encore largement chez l’enfant dans ces régions. Ce double fardeau de malnutrition constitue un problème majeur de santé publique. D’après la théorie des origines développementales des maladies chroniques non transmissibles (MNT), ces 2 fardeaux seraient étroitement liés de manière causale. L’objectif de notre étude était de retracer ses sujets avec antécédents de malnutrition aiguë sévère (MAS) durant l’enfance, d’évaluer leur devenir à long terme sur le plan socio-économique, cognitif et sanitaire, et enfin de rechercher les différents marqueurs cardio-métaboliques des MNT. Tout cela en vue d’établir une association entre MAS durant l’enfance et différentes MNT (Hypertension, diabète, obésité, dyslipidémies et composition corporelle) ainsi qu’avec le statut sociodémographique et économique à l’âge adulte, dans un contexte sans transition nutritionnelle.Méthodologie :Les dossiers de sujets admis pour MAS entre 1988 et 2007 ont été extraits des archives de l'hôpital pédiatrique de Lwiro (HPL), au Sud-Kivu, en République Démocratique du Congo (RDC). Entre décembre 2017 et avril 2019, nous avons entrepris d'identifier ces sujets dans les zones de santé de Miti-Murhesa et Katana. Les sujets d’étude ont été identifiés à partir de la base de données de l'HPL. Ils ont ensuite été recherchés dans leurs villages d’origine. Ils ont alors été répartis en quatre catégories (vivant dans le village ou ses environs, décédé, déplacé ou perdu de vue). Pour chaque ancien malnutri retrouvé, un non-exposé communautaire a été choisi de manière aléatoire pour une comparaison. Nos résultats d’intérêt étaient prioritairement les MNT incluant le syndrome métabolique, l’hypertension artérielle, l’obésité globale, l’obésité viscérale, le diabète sucré, les dyslipidémies ainsi que la composition corporelle évaluées par leurs différents marqueurs cliniques et biologiques et, accessoirement, l’atteinte rénale à travers le taux de créatinine sérique. Secondairement, nous avons évalué le capital humain à travers le niveau socio-économique (déduit à partir de la scolarité, la profession et les conditions de vie), l’estime de soi, les troubles cognitifs ainsi que les incapacités quotidiennes sur le plan relationnel et fonctionnel liés à l’état de santé. Il est signalé cependant qu’au moment de la reconstitution de la cohorte, nous avons récolté des données relatives à la survie (et son corolaire la mortalité et ses causes) ainsi que l’état nutritionnel à long terme.Résultats :Un total de 1981 dossiers des sujets admis pour MAS de 1988 à 2007 a été extrait des archives de l’HPL. L’âge médian à l’admission était de 41 mois. Six cents sujets ont été retrouvés et 201 sujets sont décédés. Soixante-cinq virgule six pourcents des sujets décédés avaient ≤10 ans lors de leur mort. Cinquante-neuf virgule deux pourcents de décès sont survenus dans les 5 ans ayant suivi la sortie de l’hôpital. Les principales causes de décès étaient le paludisme (14,9%), le kwashiorkor (13,9%), les infections respiratoires (10,4%) et les maladies diarrhéiques (8,9%). Comparés aux non exposés, les exposés avaient un faible poids (-1,7 kg, p=0,001), une petite taille [assise (-1,3 cm, p=0,006) et debout (-1,7 cm, p=0,003)], une longueur moindre des jambes (-1,6 cm, p=0,002) et un petit périmètre brachial (-3,2 mm, p= 0,051). Aucune différence n’a été observée en termes d’indice de masse corporelle (IMC), de longueur thoracique, et de périmètre crânien ou thoracique entre les 2 groupes.En termes de composition corporelle, les exposés, comparés aux non exposés, avaient une masse maigre réduite [-1,56 kg (-2,93, -0,20) ;p=0,024] mais cette observation était plus marquée chez les hommes (45,4 5,4 vs. 48,26,9 kg, p=0,01) que chez les femmes. En revanche, aucune différence entre exposés et non exposés n'a été observée en termes de masse grasse. Enfin, en ajustant pour la taille, l’index de masse maigre et l’index de masse grasse n’a montré aucune différence dans les deux groupes indépendamment du sexe.Sur le plan capital humain, comparés aux non exposés communautaires, la proportion avec niveau d’études et niveau socio-économique (NSE) élevés d’anciens malnutris était diminuée [niveau études (35,2 vs 46,4 ;p 0.) ;NSE (3,0 vs 6,7 ;p= 0,007)]. En plus, sur le plan cognitif et estime de soi, comparés aux non-exposés, les anciens malnutris avaient des scores inférieurs aux tests cognitifs [25.6 vs 27.8, p = 0.001 [Mini Mental State Examination (MMSE)] et 22.8 vs 26.3, p < 0.001(MMSE-I)] et avaient une moindre estime d’eux-mêmes (20,3% vs 12,3% ;p = 0.003). Néanmoins, en termes d’incapacités liées à l’état de santé, ces derniers avaient moins d’incapacités au plan relationnel (28,6 vs 31,5 ;p = 0.034) que la population générale, quoiqu’aucune différence n’ait été observée au plan des activités quotidiennes (5,8 vs 9,1 ;p = 0.322)En termes de MNT, comparés aux non exposés communautaires, les anciens malnutris avaient un tour de taille majoré [+1.2 (0.02,2.3) cm, p=0.015] et ratio tour de taille/taille debout supérieur [0.01 (0.01, 0.02) cm; p0.001]. Par contre, ils avaient un tour de hanches diminué [-1.5 (-2.6, -0.5) cm; p=0.021], et une force musculaire réduite. Concernant les marqueurs cardio-métaboliques de MNT, hormis une HbA1c plus élevée [+0.4 (0.2, 0.6)%; p0.001], aucune différence n’a été mise en évidence concernant la pression artérielle, la glycémie à jeun, la créatinine, le profil lipidique et l’albuminémie chez les exposés par rapport aux non exposés. En comparaison des non exposés, les exposés avaient une prévalence accrue de syndrome métabolique [Odds Ratio (OR) 2.35 (1.22, 4.54); p=0.010], d’obésité viscérale [OR ajusté 1.44 (1.09, 1.89); p=0.001] et de maigreur [OR ajusté 1.92 (1.03, 3.57)]. En revanche, la prévalence d’hypertension, de diabète, de surpoids et de dyslipidémie était similaire dans les deux groupes.Conclusion :Une MAS durant l’enfance expose les survivants à un risque élevé de MNT et à une diminution du capital humain à l’âge adulte, même en l’absence de transition nutritionnelle subséquente. Les décideurs politiques et les bailleurs de fonds souhaitant lutter contre l'expansion mondiale des MNT chez l’adulte pourraient considérer le bénéfice à long terme de la réduction de la MAS dans l’enfance en tant que mesure préventive de réduction du fardeau attribuable aux MNT au plan socio-économique.Introduction: Low- and middle-income countries are going through a nutritional transition phase that is accompanied by a rapid increase in cardio-metabolic diseases and their risk factors, such as obesity in adults, while undernutrition still predominates in children in these regions. This double burden of malnutrition constitutes a major public health problem. According to the theory of developmental origins of chronic noncommunicable diseases (NCDs), these 2 burdens would be closely causally linked. The objective of our study was to trace subjects with a history of severe acute malnutrition (SAM) in childhood, to assess their long-term socioeconomic, cognitive, and health outcomes, and finally to investigate the different cardiometabolic markers of NCDs. All this was done in order to establish an association between SAM during childhood and different chronic non-communicable diseases (hypertension, diabetes, obesity, dyslipidemias and body composition) as well as with socio-demographic and economic status in adulthood, in a context without nutritional transition.Methodology: Records of subjects admitted for SAM between 1988 and 2007 were retrieved from the archives of Lwiro Hospital, South Kivu, Democratic Republic of Congo (DRC). Between December 2017 and April 2019, we undertook to identify these subjects in the Miti-Murhesa and Katana health zones. Study subjects were identified from the Lwiro Pediatric Hospital (LPH) database. They were then traced to their home villages. They were then divided into four categories (living in or near the village, deceased, displaced, or lost to follow-up). For each former malnourished found, a community non-exposed was randomly selected for comparison. Our outcomes of interest were primarily NCDs including primarily metabolic syndrome, arterial hypertension, global obesity, visceral obesity, diabetes mellitus, dyslipidemias as well as body composition assessed by their different clinical and biological markers and, secondarily, renal impairment through serum creatinine level. Secondly, we evaluated the human capital through the socio-economic level (deduced from the education, the profession and the living conditions), the self-esteem, the cognitive disorders as well as the daily disabilities on the relational and functional level related to the health condition. It should be noted, however, that at the time of reconstitution of the cohort, we collected data on survival (and its corollary, mortality and its causes) and long-term nutritional status.Results: A total of 1981 records of subjects admitted for SAM from 1988 to 2007 were retrieved from the archives of the LPH. The median age at admission was 41 months. Six hundred subjects were found and 201 subjects died. 65.6% of the deceased subjects were ≤10 years of age at death. 59.2% of deaths occurred within 5 years of hospital discharge. The leading causes of death were malaria (14.9%), kwashiorkor (13.9%), respiratory infections (10.4%), and diarrheal diseases (8.9%). Compared to the unexposed, the exposed had low weight (-1.7 kg, p=0.001), short stature [sitting (-1.3 cm, p=0.006) and standing (-1.7 cm, p=0.003)], shorter leg length (-1.6 cm, p=0.002), and small brachial circumference (-3.2 mm, p= 0.051). There were no differences in BMI, chest length, and head or chest circumference between the 2 groups.In terms of BC, exposed, compared to unexposed, had a reduced FFM [-1.56 kg (-2.93, -0.20); p=0,024] but this observation was more marked in exposed males (45.4 5.4 vs. 48.2 6.9 kg, p=0.01) than females compared to unexposed. However, no difference between exposed and unexposed was observed in terms of FM. Finally, adjusting for height, FFMI and FMI show no difference in either sex.In terms of human capital, compared to the community unexposed, the proportion with high education and socioeconomic status (SES) of formerly malnourished was decreased [study (35.2 vs. 46.4; p 0.); SES (3.0 vs. 6.7; p= 0.007)]. In addition, in terms of cognition and self-esteem, compared to the non-exposed, the formerly malnourished had lower scores on cognitive tests [25.6 vs 27.8, p = 0.001 (MMSE) and 22.8 vs 26.3, p < 0.001 (MMSE-I)] and had lower self-esteem (20.3% vs 12.3%; p = 0.003) Nevertheless, in terms of health-related disabilities, they had less disability in relationships (28.6 vs. 31.5; p = 0.034) than the general population, although no difference was observed in daily activities (5.8 vs. 9.1; p = 0.322).In terms of NCDs, compared to the community unexposed, the malnourished elders had an increased waist circumference [+1.2 (0.02, 2.3) cm, p=0.015] and a higher waist/standing height ratio [0.01 (0.01, 0.02) cm; p0.001]. On the other hand, they had a decreased hip circumference [-1.5 (-2.6, -0.5) cm; p=0.021], and reduced muscle strength. Regarding cardiometabolic markers of NCDs, apart from a higher HbA1c [+0.4 % (0.2, 0.6); p0.001], no differences were found in blood pressure, fasting blood glucose, creatinine, lipid profile and albumin levels in the exposed compared to the unexposed. Compared to unexposed individuals, exposed individuals had an increased prevalence of metabolic syndrome [Odds Ratio (OR) 2.35 (1.22, 4.54); p=0.010], visceral obesity [adjusted OR 1.44 (1.09, 1.89); p=0.001] and leanness [adjusted OR 1.92 (1.03, 3.57)]. In contrast, the prevalence of hypertension, diabetes, overweight and dyslipidemia was similar in both groups.Conclusion: SAM in childhood puts survivors at high risk for NCDs and reduced human capital in adulthood, even in the absence of subsequent nutritional transition. Policymakers and funders interested in combating the global expansion of NCDs in adults might consider the long-term benefit of reducing SAM in childhood as a preventive measure to reduce the socioeconomic burden attributable to NCDs.Doctorat en Santé Publiqueinfo:eu-repo/semantics/nonPublishe

Barriers and Facilitators in the Implementation of Bio-psychosocial Care at the Primary Healthcare Level in South Kivu, Democratic Republic of Congo

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

Severe acute malnutrition in childhood, chronic diseases, and human capital in adulthood in the Democratic Republic of Congo: the Lwiro Cohort Study

Background Little is known about the long-term outcome of children treated for severe acute malnutrition (SAM) after nutritional rehabilitation. Objectives To explore the association between SAM in childhood, noncommunicable diseases (NCDs), and low human capital in adulthood. Methods We identified 524 adults (median age: 22 y) who were treated for SAM during childhood in Eastern Democratic Republic of Congo between 1988 and 2007. They were compared with 407 community unexposed age- and sex-matched subjects with no history of SAM. The variables of interest were cardiometabolic risk markers for NCDs and human capital. For the comparison, we used linear and logistic regressions to estimate the association between SAM in childhood and the risk of NCDs and ordinal logistic regression for the human capital. Results Compared with unexposed subjects, the exposed participants had a higher waist circumference [1.2 (0.02, 2.3) cm; P = 0.015], and a larger waist-to-height ratio [0.01 (0.01, 0.02) cm; P < 0.001]. On the other hand, they had a smaller hip circumference [−1.5 (−2.6, −0.5) cm; P = 0.021]. Regarding cardiometabolic markers for NCDs, apart from a higher glycated hemoglobin (HbA1c) [0.4 (0.2, 0.6); P < 0.001], no difference was observed in other cardiometabolic markers for NCD between the 2 groups. Compared with unexposed participants, exposed participants had a higher risk of metabolic syndrome (crude OR: 2.35; 95% CI: 1.22, 4.54; P = 0.010) and visceral obesity [adjusted OR: 1.44 (1.09, 1.89); P = 0.001]. The prevalence of hypertension, diabetes, overweight, and dyslipidaemia was similar in both groups. Last, the proportion of malnutrition survivors with higher socioeconomic status level was lower. Conclusion SAM during childhood was associated with a high risk of NCDs and lower human capital in adulthood. Thus, policymakers and funders seeking to fight the global spread of NCDs in adults in low-resource settings should consider the long-term benefit of reducing childhood SAM as a preventive measure to reduce the socioeconomic burden attributable to NCDs

Follow-up of a historic cohort of children treated for severe acute malnutrition between 1988 and 2007 in Eastern Democratic Republic of Congo

Background: It is well documented that treatment for severe acute malnutrition (SAM) is effective. However, little is known about the long-term outcomes for children treated for SAM. We sought to trace former SAM patients 11 to 30 years after their discharge from hospital, and to describe their longer-term survival and their growth to adulthood. Methods A total of 1,981 records of subjects admitted for SAM between 1988 and 2007 were taken from the archives of Lwiro hospital, in South Kivu, DRC. The median age on admission was 41 months. Between December 2017 and June 2018, we set about identifying these subjects (cases) in the health zones of Miti-Murhesa and Katana. For deceased subjects, the cause and year of death were collected. A Cox proportional hazards multivariate regression analysis was used to identify the death-related factors. For the cases seen, age- and gender-matched community controls were selected for a comparison of anthropometric indicators. Results: A total of 600 subjects were traced, and 201 subjects were deceased. Of the deceased subjects, 65·6% were under 10 years old at the time of their death. Of the deaths, 59·2% occurred within 5 years of discharge from hospital. The main causes of death were malaria (14·9%), kwashiorkor (13·9%), respiratory infections (10·4%), and diarrhoeal diseases (8·9%). The risk of death was higher in subjects with SAM, MAM combined with CM, and in male subjects, with HRs* of 1·83 (p = 0·043), 2.35 (p = 0·030) and 1.44 (p = 0·013) respectively. Compared with their controls, the cases had a low weight (-1·7 kg, p = 0·001), short height [sitting (-1·3 cm, p = 0·006) and standing (-1·7 cm, p = 0·003)], short legs (-1·6 cm, p = 0·002), and a small mid-upper arm circumference (-3·2mm, p = 0·051). There was no difference in terms of BMI, thoracic length, or head and thoracic circumference between the two groups. Conclusion: SAM during childhood has lasting negative effects on growth to adulthood. In addition, these adults have characteristics that may place them at risk of chronic non-communicable diseases later in lif

Risk of Chronic Disease after an Episode of Marasmus, Kwashiorkor or Mixed–Type Severe Acute Malnutrition in the Democratic Republic of Congo : The Lwiro Follow‐Up Study

Background: Long‐term impact of different forms of severe acute malnutrition (SAM) in childhood on the emergence of noncommunicable diseases (NCDs) is poorly known. Aim: To explore the association between subtypes of SAM during childhood, NCDs, and cardiovascular risk factors (CVRFs) in young adults 11 to 30 years after post‐SAM nutritional rehabilitation. Methods: In this follow‐up study, we investigated 524 adults (mean age 22 years) treated for SAM during childhood in eastern Democratic Republic of the Congo (DRC) between 1988 and 2007. Among them, 142 had a history of marasmus, 175 of kwashiorkor, and 207 had mixed‐form SAM. These participants were compared to 407 aged‐ and sex‐matched control adults living in the same community without a history of SAM. Our outcomes of interest were cardiometabolic risk markers for NCDs. Logistic and linear regressions models were sued to estimate the association between subtype of SAM in childhood and risk of NCDs. Results: Compared to unexposed, former mixed‐type SAM participants had a higher adjusted ORs of metabolic syndrome [2.68 (1.18; 8.07)], central obesity [1.89 (1.11; 3.21)] and low HDL‐C (High‐density lipoprotein cholesterol) [1.52 (1.08; 2.62)]. However, there was no difference between groups in terms of diabetes, high blood pressure, elevated LDL‐C (low‐density lipoprotein cholesterol) and hyper TG (hypertriglyceridemia) and overweightness. Former mixed‐type SAM participants had higher mean fasting glucose [3.38 mg/dL (0.92; 7.7)], reduced muscle strength [−3.47 kg (−5.82; −1.11)] and smaller hip circumference [−2.27 cm (−4.24; −0.31)] compared to non‐exposed. Regardless of subtypes, SAM‐exposed participants had higher HbA1c than unexposed (p < 0.001). Those with a history of kwashiorkor had cardiometabolic and nutritional parameters almost superimposable to those of unexposed. Conclusion: The association between childhood SAM, prevalence of NCDs and their CVRFs in adulthood varies according to SAM subtypes, those with mixed form being most at risk. Multicenter studies on larger cohorts of older participants are needed to elucidate the impact of SAM subtypes on NCDs risk.publishedVersionPeer reviewe

Association between diagnostic criteria for severe acute malnutrition and hospital mortality in children aged 6–59 months in the eastern Democratic Republic of Congo: the Lwiro cohort study

Background: Few studies have assessed the relationship between weight-for-height (WHZ) and mid-upper arm circumference (MUAC) with hospital mortality considering confounders. The particularity of MUAC for age (MUACZ) is less documented. Objective: This study aims to investigate this relationship in a region endemic for severe acute malnutrition (SAM). Methods: This is a retrospective cohort based on a database of children admitted from 1987 to 2008 in South Kivu, eastern DRC. Our outcome was hospital mortality. To estimate the strength of the association between mortality and nutritional indices, the relative risk (RR) with its 95% confidence interval (95% CI) was calculated. In addition to univariate analyses, we constructed multivariate models from binomial regression. Results: A total of 9,969 children aged 6 to 59 months were selected with a median age of 23 months. 40.9% had SAM (according to the criteria WHZ < -3 and/or MUAC<115 mm and/or the presence of nutritional edema) including 30.2% with nutritional edema and 35.2% had both SAM and chronic malnutrition. The overall hospital mortality was 8.0% and was higher at the beginning of data collection (17.9% in 1987). In univariate analyses, children with a WHZ < -3 had a risk almost 3 times higher of dying than children without SAM. WHZ was more associated with in-hospital mortality than MUAC or MUACZ. Multivariate models confirmed the univariate results. The risk of death was also increased by the presence of edema. Conclusion: In our study, WHZ was the indicator more associated with hospital death compared with MUAC or MUACZ. As such, we recommend that all criteria shall continue to be used for admission to therapeutic SAM programs. Efforts should be encouraged to find simple tools allowing the community to accurately measure WHZ and MUACZ.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Nutritional and health status of a cohort of school-age children born to mothers treated for severe acute malnutrition in their childhood in The Democratic Republic of Congo

Background Malnutrition is a public health problem, but outside the theoretical framework, little is known about the concrete intergenerational effects of malnutrition. Objective The objective of this study is to compare the nutritional status and health indicators of school children born to mothers who were treated for severe acute malnutrition (SAM). Methodology The study took place in Miti-Murhesa health zone in the Democratic Republic of Congo. This is a cohort study assessing the nutritional and health status of school children born to mothers who had been treated for SAM, based on WHZ or edema, in Lwiro hospital between 1988–2002 compared to children born to mothers who were not exposed to SAM. Stunting and thinness were evaluated by Height for Age Z-score (HAZ) and Body Mass Index by Age criteria (BMIAZ) respectively. On admission, blood samples were taken to assess anemia, HIV serology, hemogram and others biological indicators. Stool’s examinations were conducted by using Olympus optical microscope. Parametric and non-parametric tests were applied to compare the different variables in two groups. Results We identified 106 children aged 5–16 years (103 exposed and 58 unexposed) and we received 83.5% and 91.4% children respectively for anthropometric parameters. The mean of age was 7.9 ± 2.4 year in exposed group and 7.4 ± 2.1 year in unexposed group (p = 0.26). The prevalence of stunting was 68.3% in the exposed group and 67.3% in the unexposed group (p = 0.90). The prevalence of thinness was 12.8% in the exposed group and 9.6% in the unexposed group (p = 0.57). The biological profile (glycemia, urea, creatinine and hemogram) and the prevalence of intestinal parasites were similar in the two groups. Conclusion In this sample, in a malnutrition-endemic area, there was no statistically significant difference in nutrition and health indicators between school children born to mothers exposed to SAM and their community controls.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

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