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In Democratic Republic of Congo access to health care is limited because of many geographical and financial barriers, while quality of care is often low. Global health donors assist the country with a number of community-oriented interventions such as free distribution of bednets, antihelminthic drugs, vitamin A supplementation and vaccination campaigns, but uptake of these interventions is not always optimal. The aim of this study was to explore the perceptions of poor urban communities of the capital Kinshasa with regard to health issues in general as well as their experiences and expectations concerning facility-based health services and community-oriented health interventions. Applying an approach rooted in the grounded theory framework, focus group discussions were conducted in eight neighborhoods of poor urban areas in the city of Kinshasa in July 2011. Study participants were easily able to evoke the city’s major health problems, with the notable exceptions of malnutrition and HIV/AIDS. They perceive the high out-of-pocket cost of health services as the major obstacle when seeking access to quality care. Knowledge of ongoing community-oriented health interventions seems good. Still, while the study participants agree that those interventions are beneficial; their acceptability seems to be problematic. This is chiefly put down to a lack of information and government communication about the programs and their interventions. Furthermore, the study participants referred to rumors and the deterring effect of stories about alleged harmful consequences of those interventions. Along with improving the provision and quality of general health care, the government and international actors must improve their efforts in informing the communities about disease control programs, their rationale and benefit/risk ratio. Directly engaging community members in a dialogue might be beneficial in terms of improving acceptability and overall access to health services and interventions. Novel ways of reducing the high out-of-pocket expenditure should also be explored. © 2013 Maketa et al.
The overall health status of the population of the Democratic Republic of Congo is poor, as is reflected in several of the country’s health indicators [4]. The maternal mortality ratio is estimated at 549 deaths per 100,000 live births, with an annual infant mortality rate of 75 per 1000 live births. Malnourishment is also considered to be an important public health issue, with the proportion of under-five children in DRC suffering from chronic malnutrition estimated at 46% [5]. Furthermore, severe infectious diseases such as viral hemorrhagic fever, cholera, meningitis, plague, monkeypox, measles and poliomyelitis are epidemic threats, while other infections such as human African trypanosomiasis, tuberculosis, Buruli ulcer and malaria are endemic in the country. HIV/AIDS is also present, affecting 4.5% of the population aged 15 to 49 years [5]. This study was part of a multi-country research program initiated by the World Health Organization’s Special Programme for Research and Training in Tropical Diseases (WHO/TDR) to document perspectives of poor African urban communities on health and health care. Our study employed qualitative research and data analysis methods that are rooted within the theoretical frameworks of phenomenology and grounded theory [6,7]. Central to these approaches is the notion of understanding a certain phenomenon from the perspective of those experiencing it. They adopt an inductive approach to research, one which is not hypothesis-based, but instead takes on a bottom-up exploratory stance from which a theory or hypothesis for further research may be derived. This particular qualitative study was conducted in Kinshasa between the 11th and the 31st of July 2011, by means of a series of focus group discussions (FGDs) conducted with 16 groups of 12 persons who were recruited through faith-based organizations (FBOs) and community-based organizations (CBOs) of poor urban communities. These organizations provided us with a direct avenue through which to approach a wide range of potential participants. To minimize the influence of age, only adult participants (>25 years) were invited to participate. No additional demographic information was collected from the participants, as there was a concern this might have introduced a selection bias based on participant reluctance to provide such information. The average FGD lasted 45 minutes to an hour. Kinshasa is divided into 24 administrative zones of which 18 are classified as urban and 6 as semi-urban. For our study, 4 out of the 18 urban zones were randomly selected. These were Bandalungwa, Matete, Limete and Bumbu. Table 1 summarizes their socio-demographic characteristics. A total number of 44 neighborhoods were included in the four urban zones: 7 in Bandalungwa, 13 in Matete, 11 in Limete and 13 in Bumbu. The 4 urban zones are provided with health care services by means of ‘fixed’ health centres on the one hand, and a number of community-based health interventions on the other hand. Some of the programs implemented in recent years include the distribution of insecticide treated nets (ITN) to households, the mass distribution of vitamin A & mebendazole to under five year olds, poliomyelitis vaccination campaigns, programs for antenatal and preschool care, and health education activities on sanitation, AIDS and sexually transmitted infections (STI). Source : Annual reports 2009 of the District Health Offices of Bandalungwa, Limete, Bumbu and Matete We conducted a household survey prior to the main qualitative study to document the socio-economic level of the 44 neighborhoods in the four selected urban zones. This socio-economic survey assessed 100 randomly selected households per neighborhood. A total of 4400 households were interviewed throughout the 4 zones. Random selection of households was based on a systematic sampling interval k that was determined by dividing the number of households in the neighborhood obtained from the civil registry by 100. A first household was randomly selected following the EPI vaccine coverage survey method [8] and by considering the neighborhood’s civil administration office as the central point of the neighborhood. On the basis of these pilot data, we selected the 2 neighborhoods with the lowest socio-economic level for each of the 4 zones. There were no major differences between the 8 neighborhoods in terms of their socio-economic level. Two FGDs were organized in each of the 8 neighborhoods: one with female and one with male participants. In total, 16 FGDs were organized as shown in Table 2. The FGDs were held in Lingala, the predominant language in Kinshasa, and were recorded on audiotape. N.B : CBO : community based organization, FBO : Faith based organization. Audiotapes were transcribed verbatim in Lingala, and later translated from Lingala to French by the research team’s social scientist. The translations were verified by at least one co-investigator, who compared the translation to the original Lingala text. The data analysis was conducted by means of the French transcripts. The analysis report was later translated into English. The qualitative data analysis software package Atlas Ti was used to perform data analysis. This software allows the organizing and analyzing of unstructured datasets by fragmenting and categorizing data whilst keeping a link with the source documents (FGD transcripts in this case). General themes were identified based on the FGD question guide (Table 3) and used to create an initial set of semantic categories (community prioritization of health issues, community access to the health system, community perception of the health system, the primary care facility, health interventions, community participation and perception of the community-oriented health interventions) and subcategories that allowed for a systematic coding of the transcripts. Finally, additional codes were added during the analysis process to accommodate for supplementary themes and information that arose from the transcripts (community expectations, community suggestions, trust regarding the health system and the delivery of interventions, health system access, health system: health staff perception, community prioritization of disease, health system intervention cost, health system intervention training). Throughout this paper, we will illustrate our findings by means of excerpts taken from the FGDs. Each quote will include a reference to the relevant FGD, details of which can be found in table 2. All the audiotapes were converted to a digital format and were archived on a secured computer hard drive at the Department of Tropical Medicine of the University of Kinshasa. All original Lingala transcripts and French translations are stored on the same hard drive. The principal investigator is the only person with direct access to the data, although other research team members can be given access at their request. All data sources will be stored for a minimum of 5 years. Prior to starting the data collection, ethical approval for this study was provided by the World Health Organization (WHO) Research Ethics Review Committee in Geneva, Switzerland and the Ethical Committee of the Public Health School of the University of Kinshasa in Kinshasa, DRC. The submitted research protocol detailed the research process as described in this paper, from the selection of the included neighborhoods to the implementation of the FGDs. Participation in the study was entirely voluntary and based upon the participant signing a written informed consent form.
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