Strengthening nutrition services within integrated community case management (iCCM) of childhood illnesses in the Democratic Republic of Congo: Evidence to guide implementation.

In the Democratic Republic of Congo, 43% of children under 5 years of age suffer from stunting, and the majority (60%) of children, 6-59 months of age, are anaemic. Malaria, acute respiratory infections, and diarrheal diseases are common among children less than 5 years of age, with 31% of children 6-59 months affected by malaria. This qualitative implementation science study aimed to identify gaps and opportunities available to strengthen service delivery of nutrition within integrated community case management (iCCM) at the health facility and community level in Tshopo Province, Democratic Republic of Congo, through the following objectives: (a) examine cultural beliefs and perceptions of infant and young child feeding (IYCF) and child illness, (b) explore the perspectives and knowledge of facility-based and community-based health providers on nutrition and iCCM, and (c) gain an understanding of the influence of key family and community members on IYCF and care-seeking practices. This study involved in-depth interviews with mothers of children under 5 years of age (n = 48), grandmothers (n = 20), fathers (n = 21), facility-based providers (n = 18), and traditional healers (n = 20) and eight focus group discussions with community health workers. Study findings reveal most mothers reported diminished quantity and quality of breastmilk linked to child/maternal illness, inadequate maternal diet, and feedings spaced too far apart. Mothers' return to work in the field led to early introduction of foods prior to 6 months of age, impeding exclusive breastfeeding. Moreover, children's diets are largely limited in frequency and diversity with small quantities of foods fed. Most families seek modern and traditional medicine to remedy child illness, dependent on type of disease, its severity, and cost. Traditional healers are the preferred source of information for families on certain child illnesses and breastmilk insufficiency. Community health workers often refer and accompany families to the health centre, yet are underutilized for nutrition counselling, which is infrequently given. Programme recommendations are to strengthen health provider capacity to counsel on IYCF and iCCM while equipping health workers with updated social and behavior change communication (SBCC) materials and continued supportive supervision. In addition, targeting key influencers to encourage optimal IYCF practices is needed through community and mother support groups. Finally, exploring innovative ways to work with traditional healers, to facilitate referrals for sick/malnourished children and provide simple nutrition advice for certain practices (i.e., breastfeeding), would aid in strengthening nutrition within iCCM.

A Congolese community-based health program for survivors of sexual violence.

Many survivors of gender based violence (GBV) in the Democratic Republic of Congo (DRC) report barriers to access health services including, distance, cost, lack of trained providers and fear of stigma. In 2004, Foundation RamaLevina (FORAL), a Congolese health and social non-governmental organization, started a mobile health program for vulnerable women and men to address the barriers to access identified by GBV survivors and their families in rural South Kivu province, Eastern DRC. FORAL conducted a case study of the implementation of this program between July 2010-June 2011 in 6 rural villages. The case study engaged FORAL staff, partner health care providers, community leaders and survivors in developing and implementing a revised strategy with the goal of improving and sustaining health services. The case study focused on: (1) Expansion of mobile clinic services and visit schedule; (2) Clinical monitoring and evaluation system; and (3) Recognition, documentation and brief psychosocial support for symptoms suggestive of anxiety, depression and PTSD. During this period, FORAL treated 772 women of which 85% reported being survivors of sexual violence. Almost half of the women (45%) reported never receiving health services after the last sexual assault. The majority of survivors reported symptoms consistent with STI. Male partner adherence to STI treatment was low (41%). The case study demonstrated areas of strengths in FORAL's program, including improved access to health care by survivors and their male partner, enhanced quality of health education and facilitated regular monitoring, follow-up care and referrals. In addition, three critical areas were identified by FORAL that needed further development: provision of health services to young, unmarried women in a way that reduces possibility of future stigma, engaging male partners in health education and clinical care and strengthening linkages for referral of survivors and their partners to psychosocial support and mental health services. FORAL's model of offering health education to all community members, partnering with local providers to leverage resources and their principal of avoiding labeling the clinic as one for survivors will help women and their families in the DRC and other conflict settings to comfortably and safely access needed health care services.