Organisational learning from community feedbacks on COVID-19 restrictive measures and health management self-reliance perspectives: a socio-anthropological case study in Bukavu, DRCongo

Organisational learning from community feedbacks on COVID-19 restrictive measures and health management self-reliance perspectives: a socio-anthropological case study in Bukavu, DRCongo | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Organisational learning from community feedbacks on COVID-19 restrictive measures and health management self-reliance perspectives: a socio-anthropological case study in Bukavu, DRCongo Christian Ahadi Irenge, Parfait Kaningu Bushenyula, Eben-Ezer Genda, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6215975/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Central African countries face global health problems caused by emerging diseases that have significant social and economic impacts such as Ebola, COVID-19, HIV/AIDS, Chikungunya, Rift Valley Fever, Avian Influenza, Newcastle Disease, etc. The efficient management of emerging diseases often involves restrictive and constraining responses to fundamental rights, which require long-lasting social and health security schemes. The governments have not yet been able to establish these schemes in Central African countries. In this difficult conjuncture, it is important to question the integration of the situations of poor communities as well as the responsibilities in view of the self-reliance of health management strategies. Particularly, the COVID-19 pandemic has led governments to apply restrictive control measures that have required a sudden behavioral change in the population. For organizational learning, it is necessary to analyze situations of resistance to COVID-19 response measures. Using a socio-anthropological survey this study provides a retrospective community feedback and discusses organizational perspectives from the experience of first wave COVID-19 restrictive measures in Bukavu city, South Kivu, Democratic Republic of the Congo. Methods A qualitative study was conducted between April and July 2020 in Bukavu town, South Kivu, DR Congo. We used a socio-anthropological survey and a literature documentation for discussion. A total of 86 individual semi-structured interviews lasting a maximum of one hour and 5 focus groups discussions were conducted in the three communes (Ibanda, Bagira and Kadutu) of the city of Bukavu. Various stakeholders have participated to the survey such as unformal drug seller, students, shopkeeper, household responsible, state health agencies workers, unemployed youth, clinical healthcare providers, housewives, adult without schooling, a lawyer and clinical healthcare providers in the COVID-19 treatment center. These interviewed actors were selected through convenience sampling. First, they were selected based on their availability and willingness to participate in the study. Also, the informants were targeted according to the information we aimed to collect from them. The theme explored during the individual interview and focus group discussion was the community perception on restrictive COVID-19 measures and behaviors risks; and the factors that represent obstacles to the adoption of the response measure. The interview recordings were translated and transcribed. We used the thematic analysis method to progressively present and discuss the survey results by identifying recurring themes from the data. Results: The study revealed cases of the community members understanding of the scientific characteristics of COVID-19, their perceptions about the geographical emerging of the COVID-19 pandemic, their business opinions on the emergence of COVID-19 and the cultural and religious labeling of the pandemic. Also, community feedback on restrictive COVID-19 measures is enhanced and explicitly puts forward the expectations and suggestions, constraints to implement these measures. Moreover, it’s raised from the stakeholder’s opinions, the perspective for self-reliance in the strategies and resources in health risk management. In this regard, the analyze emphasis on the key role of stakeholders from the south in the dialog for change aiming at self-reliance in the health risk communities’ perceptions, strategies and resources. Conclusion: The dynamics in attitudes observed within the community brings out the challenges of community engagement in the context of COVID-19. The response to COVID-19 has resulted in the need to apply restrictive measures that have required a behavioral change in the population. Therefore, investigating the perceptions and determinants of implementation of restrictive measures is a good approach. However, to ensure these elements bring added value to the implementation of the health risks response, they should be integrated on the basis of a participatory consultation considering the resources available in the management program. COVID-19 restrictive measures health risk management self-reliance 1 Introduction Establishing strategies to respond to emerging diseases is a complex challenge in fragile system contexts with inadequate capacity in health security and surveillance and preparedness for major health emergencies. The nature of the risk in emerging diseases, such as the COVID-19 pandemic, requires well-coordinated health response strategies: crisis management must be reactive, based on a constantly updated situation analysis, prospective modeling, and feedback. 1 Indeed, the risk communication and community engagement (RCCE) is one of the pillars of engagement in epidemic response. This is because individuals and communities remain the primary actors and decision makers in efforts to promote individual and collective actions related to prevention and response. 2 According to the World Health Organization (2020), RCCE is about transparent communication to the public about what is known about the epidemic, what is not known and what is being done. Then, announcing any changes in the response strategy as well as interventions in preparation. It is also about communicating with empathy in local languages and considering cultural values. 2 In addition, it is important to disseminate up-to-date and useful health advice through reliable communication channels, and then to check how the messages are interpreted by the communities. 2 It is therefore recommended that systems be put in place to detect and respond to expectations, rumors and misinformation. 3 For example, the "Ebola kills" message during the RDC’s Ebola outbreaks declared in August 2018 led people to believe that the disease was incurable. People then chose to die at home rather than go to treatment centers, which contributed to the spread of the disease. 2 , 4 Similarly, messages regarding the COVID-19 pandemic should be tested to ensure that they are clear and do not cause unwanted behavioral changes. As in several countries in the South, the DR Congo has developed a multisectoral strategic plan against the COVID-19 epidemic that is anchored in the country's health system and is in line with the control strategies proposed by the WHO. 5 The analysis of the situation that justifies this investigation is the fact that after the experience of the COVID-19 crisis, several evidences show that the community context of the city of Bukavu has had an adverse impact on the progress of the COVID-19 response. Several points can be raised from the documents consulted. In some cases, the coordination of the response has been hampered by a failure to mobilize the community in the response. One illustrative case is the resignation of Nobel Prize 2018 winner Dr. Mukwege, one of the leaders of the response, an actor who was trusted by the population. Also, there have been reports of contradictions in communication between the national and regional levels of management of COVID-19 6,7 . In addition, the methods used to incentivize the adoption of the response measures would have weakened the participation of the population. As well, we have witnessed demonstrations of denial by the population of the existence of cases of COVID-19 as well as collective refusal marches of barrier measures such as in the commune of Ibanda (Major Vangu venue) and Bagira (Makoma venue) in Bukavu Town. For organizational learning, it is necessary to analyze the cases of resistance and non-compliance with COVID-19 response measures. For this study, the aim is to analyze the perceptions and practices of the population in the context of the city of Bukavu, in the province of South Kivu, in DR Congo. South Kivu is identified^ as one of the poorest provinces in the country alongside Equateur and Bandundu: almost six out of seven inhabitants live below the poverty line 8 . South Kivu, like most of the DRC's provinces, suffers from inadequate infrastructure and of health personnel. This region has a considerably high morbidity and mortality rate of infectious diseases such as malaria, cholera, tuberculosis, respiratory infections, diarrheal diseases, etc. 9 It is this situation of a fragile health system that should face the COVID-19 pandemic. Using a socio-anthropological survey and a literature review this paper provides a retrospective community feedback and perceptions on the first wave COVID-19 restrictive measures in Bukavu city, South Kivu, Democratic Republic of the Congo. 2 Objectives The objective of the investigation is to contribute to describe, through a socio-anthropological study, the different socio-economic and cultural perceptions that represent obstacles or enabling factors to the adherence of the population to the restrictive COVID-19 measures, in South-Kivu, DR Congo. 3 Materials and methods 3.1 Study environment This research was conducted in Bukavu city located in the Province of South Kivu in Eastern DR Congo between April and July 2020. This province covers an area of 44.90km2, with an estimated population of 1,514,282, and it is a region where living conditions require resilience to the impacts of decades of armed conflict and political and economic instability. The population of the region has adapted to live in conditions of social and economic imbalance due to rural exodus, loss of investment, and weakened educational and health infrastructure. Also, the conditions of imbalance are maintained by the insufficiencies in the governance of public services. On the other hand, decades of political and security instability have led to a severe economic recession. The decline in GDP per capita during this period was 27 percent. Thus, human development indicators deteriorated. The emergence of COVID-19 in this same context, as well as the application of COVID-19 restrictive contingency measures, led as a result to additional social disruptions and losses of substantial income resources. These weaknesses in the system may have posed threats to the community's commitment to the restrictive measures of the COVID-19 response. 3.2 Design of the study Data collection methods and interview guide For conducting this case study, we have used a socio-anthropological investigation 10 and a literature documentation for discussion 11 . The investigation was conducted in the 3 communes of the city of Bukavu between April and July 2020. For the sampling method, the interviewed actors were selected through convenience sampling 14 . First, they were selected based on their availability and willingness to participate in the study. Also, the informants were targeted according to the information we aimed to collect from them in relation to either their professional expertise, their personal experiences of the COVID-19 crisis and their educational and social levels. The sample size were realized with the data collected saturation (redundancy of data provided by respondents). Data collection procedure consisted on the one hand, an exploratory survey conducted with key participants including academics, health professionals including technical agents of the COVID-19 response and community members. The objective of the exploratory survey was to involve these stakeholders in the study design 12 . They were consulted in order to (i) validate the objectives, (ii) adapt the interview guide, (iii) target the people to be interviewed, and (iv) determine the expectations of the stockholders with regard to the investigation. On the other hand, an in- depth investigation was made by organizing semi-structured interviews and 5 focus group discussions with 86 participants (Table 1) to make analysis how the attidudes of these different menbre of the population could influence the adoption to COVID-19 measures (Table 2 ) 13 . We have used an interview guide with open question. The theme explored during the individual interview and focus group discussion was the community perception on restrictive COVID-19 measures and behaviors risks; and the factors that represent obstacles to the adoption of the response measure. The Table 2 present the detailed themes and sub-themes explored in the interview guide. The interview recordings were translated and transcribed. We used the thematic analysis method 15 and inductive analysis of qualitative data 16 to progressively present and discuss the survey results by identifying recurring themes in the data. 3.3 Ethical considerations Because this study involves humans, the study respondents have given verbal free and informed consent to participate to the study. They were also consulted for their permission to record the interviews. During field data collection, local traditions, folk customs, norms and values have been respected. Also, the ethical principles of respect for persons, respect for the interests of the respondent́, justice, and respect for communities have been observed. The study was approved by the ethical committee of the Official University of Bukavu, Bukavu, Democratic Republic of the Congo. 4 Results 4.1 Brief description of the DRC COVID -19 response plan The notification of the first case of COVID -19 called on the government, with the support of its partners, to develop a strategic plan for the response to COVID 19. Together, they set out to reframe a multisectoral plan against the epidemic to ensure an effective response. In general, the objective was to contribute to interrupting the transmission of COVID -19 and minimizing its health and socio-economic impact throughout the DRC for a period of 12 months. “In DRC Congo, experiences from the 10th Ebola outbreak were capitalized on at several levels including coordination, laboratory and case investigation, medical management, infection prevention and control, and community engagement and logistics. At the community engagement level, which is one of the most important steps, certain strategies were developed, including the development of key messages, rumor management, production and dissemination of communication tools, awareness raising, advocacy, and the use of the green line. The strategic plan was then supported by the humanitarian response plan. It describes the humanitarian needs and the response to be implemented to assist the most vulnerable people affected directly or indirectly by the epidemic” 17 . 4.2 Information about the study participants and theme explored Tableau 1. Characteristics of respondents interviewed Profession/Occupations Numbers Communes in Bukavu Town M Male FE Female Bagira Kadutu Ibanda Unformal Drug Sellers 2 4 1 2 3 Students 9 5 4 3 7 Small shopkeepers 10 0 3 3 4 Household responsible 6 3 4 2 3 State Health workers 4 1 0 1 4 Unemployed youth 7 3 2 6 2 Clinical healthcare providers 5 7 4 4 4 Housewives 0 10 4 3 3 Adults with no schooling 5 1 1 3 2 Lawyers 1 0 0 0 1 Clinical healthcare providers in the COVID-19 treatment center 1 2 1 0 2 Total 50 36 24 27 35 Table 2: Themes explored in the interview guide Table 2 summarize together the questions formulated prior to data collection. On the other hand, it presents the main sub-themes formulated from the opinions collected during the interviews. The sub-themes derived from the interviews represent the experiences of the participants in the study and will mainly be the object of analysis and discussions. Themes prior to data collection Themes Perceptions of COVID-19 Response management COVID-19 response measure practices Knowledge and perception of COVID -19 diseases Perception of restrictive COVID -19 control measures Sub- themes Positive and negative aspects of COVID-19 response -COVID 19 response measure problems -Contrast of compliance -Exitance -Recognitions -Treatment and prevention impact -Mask wearing -Hand sanitizer use -Confinement -Lockdown -Travel restrictions Data sub-themes and discussion elements Sub-themes - Necessary mitigation actions applied -Ineffective Awareness and community engagement - Self-reliance need for health strategies and resources - Transparency gap in epidemiology reporting - Involvement of communities in the decision requirement -Main constraint are low economic means, community awareness gaps, side cultural influences, etc. - Community expectations and suggestions: subsidies for protection and testing materials, etc. - Community need of information: symptoms, curative treatments, differences between the races, maximum duration of the crisis, identity of the of people affected . -Incidence of the COVID-19 pandemic -Conspiracy theory and business views -Pandemic Cultural and religious labeling - Measure are important -Social distancing difficult to apply -Confinement is impossible - Application of well-structured incentives required Discussion - Increasing acquisition information about COVID-19 amplifies compliance. 20 -Health sector challenges: inadequate human resources, inadequate budgetary allocation to health and poor leadership and management. 41 -Sustained domestic and external investment. 42 - Compliance facilitators in COVID-19 crises are informational support and social responsibility. 33 -Barriers to compliance included inconsistent rules, caring responsibilities, fatigue, etc. 33 - Compliance was lower for people who lacked the practical capacity to follow the COVID-19 measures. 26XX - Social-distancing compliance is higher when combining with economic and fiscal interventions. 30 _ Spirituality was linked to a higher possibility of COVID-19 vaccine refusal. 39 -Religion was associated with the frequency of interactions against social distancing measures. 40 -Consider a society's cultural attributes effective policy responses. 37 -Misuse of epidemic response funds in DRCongo. 22 -Fight against corruption in health sector 42 -Religious Clerics had poor COVID-19 practice and negative attitudes. 38 - conspiracy theory decreased institutional trust, adoption of physical distancing, and social engagement. 36 -Interventions developed rapidly and could not be informed directly by evidence. 32 -Self-interest and health concerns motivated compliance in COVID-19. 28 - Self-discipline did not work for everyone 26XX - Lockdown measures may have helped inhibit community transmission 29 -Lockdown posed considerable economic costs and deleterious effects on cultures. 34 4.2 Common perceptions of COVID -19: between denial of the existence of the COVID -19, socio-financial influences, the importance of barrier measures and the population's risk behavior In Africa, and particularly in the DRC, epidemics are not new phenomena. Since the tintroduction of Vibrio cholera in 1974, countries have experienced recurrent epidemics every year. Many of these are related to the increased mobility of goods and people who have been in intercontinental contact. Other epidemics such as malaria, meningitis and measles are water-related and often regular in areas where they are endemic 18 . When the COVID-19 pandemic emerged in Wuhan province in China in November 2019 19 , various perceptions fueled by rumors were heard in the city of Bukavu that impacted the acceptability of the response measures to COVID-19. Until the announcement of the first case in Bukavu, rumors changed with each passing day and gained space for debate. The origin of the disease seemed dark to most of the population. Despite the fact that reliable scientific experiments explain the source of COVID-19, some people were indignant about the situation while others relied on their personal beliefs. This is why, in order to understand the perceptions of the population of Bukavu (Table 3), it is important to question the public discourse and the hidden or backstage discourse. Table3: Perceptions of COVID-19 , the response management and the restrictive measures Sub-themes Community opinions Incidence of the COVID -19 pandemic - Uncertain existence due to the lack of tangible evidences - Coming from the “White people”. - Surprise and anxiety following the appearance of COVID 19 Conspiracy theory and business views - Existence of COVID -19 but prevalence data are increased by the authorities - People are fearing going to hospital for fear of being killed, they prefer the treatment from home that increase the contamination - A business for the authorities to earn money - COVID Montage, COVID Business, COVID-COP, " Handing over and taking over between Ebola and COVID -19 ". Cultural and religious labeling - The population thinks that COVID -19 is a satanic disease, for example because of the closing of the churches, but the markets are working - "Hair between the pages of the Bible" is put in water as a medicine - Closing the churches is a good measure, but it has lasted many months already Understanding of the scientific nature of COVID-19 - Disease that emerged from China - A zoonosis transmitted by either pangolin or snakes Response measures: Confinement, Hand sanitizer use, mask wearing, hand washing, social, etc. - Are good and effective if they are respected - Do not agree with closing schools and churches as well as confinement - Confinement is impossible given the low socio-economic means and it would be good if the State helped people to survive - Social distancing is a good measure but difficult to apply in our context - Hand washing: good measure against COVID-19 and other diseases Management of COVID-19 in South Kivu - Good because there are those who heal - Bad because some hospitals charge for the treatment of this disease - Awareness and community engagement are ineffective - Communication is ineffective due to lack of trust, awareness, rumors and contradictions in the response team Thus, these perceptions can be explained by several elements, including four main ones as revealed by our study: Perceptions about the incidence of the COVID -19 pandemic: "A disease from the Whites” First, when it emerged in the community, COVID-19 has been described as a western "white man's disease “that can only kill whites, not Africans. When the virus had already spread with great morbidity all over the world, with the exception of several African countries, it became a way to make assumptions that would justify it. On the one hand, at the international level, some scientists put forward the hypothesis that Africa will not be much affected due to its geographical position dominated by the warm climate, the virus would not be resistant there. Others have shown that the organism of the Africans used to the regular consumption of anti-malaria drugs strengthens its humility. In addition, it has been hypothesized that Africa has a predominantly young population, so that COVID -19 would directly attack the elderly and others with co-morbidities 9 . While the above perceptions are not the same as what said, the World Health Organization Director General Tedros Adhanom Ghebreyesus : “the best advice for Africa is to prepare for the worst and to prepare today " 20 . A Housewives told us: "(...) this is one more misery in our life and it comes from the Occident among the Whites because we didn't know that such a tragedy was going to happen to us, the children don't study anymore, and those who have studied don't have jobs...". (extract from an interview with a Housewives, Bukavu-DRC, April 2020), The emergence of COVID-19: the business views Secondly, COVID-19 is perceived to be a human invention, a "white man's invention", manufactured in a European laboratory. In the same logic, it is also considered as a biological weapon against some states of the world, especially those in political and economic conflicts. Talking about a human invention for epidemics is not a first in the history of epidemics in the DRC. During the Ebola epidemic in eastern DR Congo that was declared in August 2018, it was one of the forms of misinformation that led communities to strongly resist humanitarian response actions. A similar situation was observed during the vaccination activities where at the time, some households resisted the vaccination of their children. On the one hand, populations are insufficiently informed or sensitized, on the other hand, vaccines are considered experimental and have negative effects such us the Ebola vaccines ChAd3-SUDV, CAdOx1 and SV-SUDV 21 . All of this leads the population to rely much more on the different misinformation circulating in the environment and which have rarely been contradicted by the specialized body in communication and listening. The cultural and religious labeling of the pandemic Third, COVID 19 is perceived as a punishment from God (divine punishment) or "Pigo la Mungu" in Swahili. It is in the sense that it has attacked the whole world as a result of the extreme sins of men on earth. Some the people from Bukavu, God has revealed himself and acted as in the ancient times when he punished through acts and words. In Bukavu, some church representativess had recuperated the discourse of the population by certifying God's share of the responsibility for COVID-19. Through the radio programs that they hosted, most of the preaching revolved around the pandemic, with the posture of proving to Christians the wrath of God so that they would repent. A resident of the commune of Kadutu said: "There was a time when a preaching was circulating on social networks through which an evangelist claimed to have had a revelation from God regarding COVID 19. The so-called God-Man said that God revealed to him the medicine to cure COVID -19 and that it was simple. All you have to do is to have a bible and open it to look for a hair to put in a glass of water and drink in order to heal and not to get COVID-19 anymore. I assure you, many people believed in this and did not hesitate to do it.” (extract from an interview with an inhabitant of the commune of Kadutu, Bukavu/DRC, May 2020). Another continues: "At the beginning, people talked about the "Hair of the Bible". People started to look for hair in the bible that they would put down to drink to protect themselves from COVID-19.” (extract from an interview with COVID-19 response committee staff, Bukavu/DRC, May 2020). In addition, there is also the habit of the population to be regularly in contact for family, religious, commercial activities, etc. has constituted a barrier for the COVID-19 measures as social distancing. In the city of Bukavu, the evidence of the non- adoption of measures has been multiple and is manifested through the mis respect of confinement, isolation and social distancing. In order to survive the socio-economic conditions, people are forced to distrust these measures while the government fails to find alternatives to provide for its population. A Professor of University says: "First of all, at the social level: people are used to living together here in the name of African solidarity, when we are forced to confine ourselves, it is really negative compared to our usual life. These are only new habits that have been asked of us: confinement, isolation, quarantine". (Extract from an interview with a Professor, Bukavu-DRC, July 2020). Cases of community understanding of the scientific nature of COVID-19 Fourth, beyond the misinformation, there was another part of the population that believed in the existence of the disease. Within their communities, these people showed interest in practicing precautionary measures. In the meantime, they called on those around them to adopt the recommendations of the WHO and the provincial government in charge of public health. A student at one of Bukavu's universities said: "For me and my family we believed in it and the others took it as a business deal…" (extract from an interview with a student, Bukavu-DRC, April 2020). But in practice, the provincial policy has not made it easy for the population to take ownership of the response activities. In view of all these perceptions linked to misinformation and rumors within the population. Communication and community involvement are important and indispensable in the response to an epidemic due to its danger and contagiousness. The response measures raise socio-economic issues that require community support. Also, listening to the people involved is also one of the components of effective communication. In this context, the radio was the most frequent source of information for the population and for others, information was received in the community through friends, relatives, acquaintances, neighbors, etc. Also, some billboards and posters were used to raise awareness. Furthermore, the technical agents involved in the response showed particular motivation and gave more importance to the application of the response measures. A health worker at the Response Center confided to us: "... First of all, we must ignore this African solidarity and Christianity and respect the barrier measures first. These are the measures that will allow us to resume our activities as before without any problems." (extract from a health care worker at the COVID-19 /Bukavu/Kadutu/DRC Response Center, June 2020). 4.3. Community feedback on the response to COVID-19 Table 4 summarizes information related to the population's expectations of the response team, constraints to implementing the response measures, needs to know about COVID-19 and suggestions for response measures formulated by the population of Bukavu city at the start of the pandemic in April 2020. Tableau 4: Population expectations, constraints to implementing response measures, information needs on COVID-19 and suggestions for actions in the response Sub-theme Expectations and suggestions Need of informations Constraints to implement the measures Subsides application -Installation of taps for hand washing, the distribution of hand sanitizer as well as nose mask - Communicate identities of the people affected - The promotion and aid to young entrepreneurs -To know the cost of the COVID-19 treatment - Lack of financial means Response management -Carry out the rapid analysis test at the provincial level to avoid sending samples to the capital city - Publication of the real prevalence - No lockdown do avoid economic side effect - Open Churches and maintain public market - Standardize the treatment over the whole country - Financial assistance to the population listening to the population -The maximum duration of the crisis - Possible resurgence of the epidemic - To know the symptoms, curative treatments - Disease said to be invented by the politicians as to get funding from international partners - Misunderstanding between the persons in charge of the response - Gap in the community engagement activities - Lack of resources (funds, laboratory equipment, qualified personnel, health risks preparedness strategies, etc). Incitatives for measures application - Rigor and to convince the population of the existence of the pandemic. - Strengthen the monitoring of barrier measures application -To know the existence of differences between the races -To know the identity of the of people affected - The negligence of mitigation measures - The lack of belief in the existence of the disease - Cultural perceptions e.g. COVID is a satanic diseases leading to close churches - Social interaction (greetings, help, wedding, bereavement, peacebuilding grouping, etc). 4.3 Self-reliance perspectives of strategies and resources in health risk management Fifth, from the interviews, we can raise in the opinion that the importance is more given to the resources coming from the international aid to the detriment of the potential resources and local initiatives in the management of the risks. The same is true of the respondent’s’ prioritization of the application of response strategies recommended by international agencies without much attention to the need to adapt the strategies to the local contexts. This study found several instances where more emphasis is placed by interviewees on prioritizing international assistance. One lawyer told us: "I see for example for Ebola we were talking about Ebola montage, Ebola Business, Ebola business etc. When the coronavirus disease was declared in Kinshasa, it was said that there is a handover and recovery between Ebola and COVID-19" (extract from an interview with a lawyer, Bukavu/DRC, May 2020). According to student: "The response agents and the government are playing with us to get the funding. As a result, the population has started to disobey the recommendations of the authorities. At my home in Bagira, for example, you have to hide your mask because since the death of a citizen by a police officer following the disrespecting of wearing a nose masks, the population has said to themselves that they should no longer wear them, so that the police would kill all the people" (extract from an interview with a student in the commune of Bagira, Bukavu/DRC, July 2021). On the other hand, informants pointed out that the recommendations for managing the pandemic formulated by international organizations are prioritized by the COVID-19 Response organization 5 instead of adapting the strategy to the context. This is the example of the student who said that: "If you tell him to stay at home and in the evening, I will bring you food for the children, I assure you everyone can stay at home. Otherwise, it is not possible. How? and the children? You're going to tell someone to stay home when they don't know how to eat? I don't think that's humane. Elsewhere, like in France, people have been asked to stay at home, but at least the government gives them subsidies" (extract from an interview with a student in the commune of Ibanda, Bukavu/DRC, July 2021) From this perspective, we can emphasize two situations related to two types of actors. First, the health institutions that remain dependent on external aid for health responses. This is due to the difficulties in mobilizing new resources or allocating existing resources to priority problems in accordance with the health management ethical principle of utilitarian justice. Utilitarian justice stipulates the prioritization of strategies aimed at guaranteeing the well-being of the vast majority of the population. In addition, the poor management of resources allocated to health risk management in general. For example, former DR Congo Health Minister Oly Ilunga Kalenga was condemned to five years of hard labor for the misuse of funds to address Ebola in the east of the country 22 . Indeed, the health sector is an attractive sector for corruption. The availability of foreign aid for health has also fueled corruption globally. Corruption limits access to health services and weakens all the dimensions that determine good health system performance: equity, quality, responsiveness, efficiency, and resilience, and also affects outcomes and lives. It is estimated that the world spends more than US$7 trillion on health services and that at least 10-25% of global spending is lost directly to corruption, amounting to hundreds of billions of dollars lost each year. These billions lost to corruption exceed WHO estimates of the amount needed each year to make up the shortfall to achieve universal health coverage worldwide by 2030 23 . Secondly, with regard to the suspicion of misappropriation of funds, the population refers to the embezzlement of funds from international aid and not the country's own funds that would be allocated to the response. In addition, community actors (referring to the lifestyle of NGO employees) perceive that they are better off compared to the income of the employees of the state agencies. These opinions are reinforced by the lack of information among the population regarding the impacts of NGO projects. This is why public opinion suspects that there is business activity every time a new epidemic emerges. These perceptions constitute an obstacle to the acceptance of the actions of interventions in partnership with NGOs. According to the Quebec association of international cooperation organizations, the valorization of knowledge from the countries of the South and the need to give back to communities the power over their development call for a decolonization of thoughts and practices, in order to establish a true cooperation, fully respectful of the people 24 . Partnerships with international health institutions are very beneficial in the development of intervention strategies for epidemic management. Also, these partnerships provide technical, operational and financial support that is very beneficial for some countries in the South with fragile systems in terms of organization of surveillance and prevention of emerging diseases. Nevertheless, as raised in our analysis, there is an increasing prioritization of resources that come from international aid to the detriment of local initiatives. These locals’ initiatives include national resources (existing and other financial resources that need to be developed) to be used in an appropriate way, human resources that need to be capacitated, disease surveillance and detection plan that needs to be strengthened, etc. From the perspective of self-reliance (Table 5), for autonomy of initiative in the development of health management strategies, there is a great responsibility of health systems in the South. That’s to establish risk analysis bodies that are mandated to formulate strategies for action and to contextualize the recommendations of international institutions. In order to have the autonomy to initiate intervention strategies, it is necessary to set up health risk analysis and management bodies. These bodies should be capable of identifying risk agents, selecting toxicological reference values, assessing population exposures, characterizing health risk 25 and generating, evaluating and selecting health risk management options. Tableau 5: Self-reliance of strategies and resources for health management Results from interviews Self-reliance for resources raising - The health institutions that remain dependent on external aid for health emergent responses. - Difficulties in mobilizing new resources or allocating existing resources to priority problems. - The poor management of resources allocated to health risk management. Eg. the former Minister of Health of the DR Congo, Oly Ilunga Kalenga, was sentenced to five years of hard labor for embezzling funds intended for the fight against the Ebola virus 22 Self-reliance for strategies development -Prioritization of the application of response strategies recommended by international health organizations without much attention to the need to adapt the strategies to the contexts. -The responsibility of health systems in the South is to establish risk analysis bodies that are mandated to formulate strategies. -This bodies should be able of identifying risk agents, selecting toxicological reference values, assessing population exposures, characterizing health risk. Self-reliance about the community perceptions - The population refers to the funds from international aid and not the country's own funds that would be allocated to the response. - Increasing prioritization of resources that come from international aid to the detriment of local initiatives - Community actors (referring to the lifestyle of NGO civil servants) perceive that they are better off compared to the income of the Congolese civil service. - Lack of information among the population regarding the impacts of NGO projects. - Common opinion suspects that there is business activity every time a new epidemic emerges and NGO partnerships. E.g., an obstacle to the acceptance of the actions of interventions in partnership with NGOs. 5 Discussion This work describes and discusses case lessons from the experience of restrictive measures the COVID-19 epidemic of the population of the city of Bukavu, South Kivu, DRCongo. This case study presents organizational learning opportunities on community feedbacks on COVID-19 restrictive measures and health management self-reliance perspectives from the experience of a small number of community and health members. The results produced provide a solid basis for qualitative studies with a larger number of participants, as well as quantitative studies and statistical analyses to establish relationships between different determinants. First, we have described cases of the community members who had clair understanding of the scientific characteristics of COVID-19. Although these people showed interest in practicing barriers measures, the communication and community participation strategies of the response has not strengthened the community ownership of the response activities. A study on compliance with COVID-19 mitigation measures noted that intrinsic (moral and social) motivations promoted compliance. Yet appeals on self-discipline did not work for everyone, compliance was lower for people who lacked the practical capacity to follow the measures and for those who have the opportunity to break the measures. 26 Further in line with our results, Benjamin van Rooij and al. brought to light that compliance COVID-19 restrictive measures depended as well on people’s intrinsic motivations, including substantive moral support and social norms. 27 Also, a study revealed self-interest and health concerns motivated compliance, normative concerns regarding duty to support the authorities dominated compliance decisions in COVID-19 response. 28 Secondly, our findings draw lessons from community feedback on restrictive COVID-19 measures while enhancing the suggestions that can have a positive influence on compliance. We have enhanced the people expectation and suggestion to enable the compliance such us the transparency in epidemiology report, subsidies of protection and testing materials, application of well-structured incentives, involvement of communities in the decision, etc. Faced with doubts about the existence of COVID-19 cases, many community members have attached importance to the possibility of publishing the identities of people affected in order to reassure themselves. This being impossible in view of the obligation not to violate patient confidentiality, it points to the need for transparency in epidemiological reporting to engage people in the response. A study have described the design of lockdown measures in nine countries in sub-Saharan Africa and fund that while lockdown measures may have helped inhibit community transmission, the pattern and nature of the epidemic remains unclear. 29 Concerning restrictive COVID-19 measures, respondents have given particular attention to the perception that Social distancing is a good measure but difficult to apply in our context of Bukavu town and confinement is impossible given the low socio-economic means. The confinement might work if the state helped vulnerable people to survive. Based on a sample of Africa countries findings suggest that compliance with COVID-19 social-distancing is higher in countries applying strict containment measures. Also, people compliance with social-distancing measures is higher when combining lockdown measures with economic and fiscal interventions. We also find that access to the internet or increasing acquisition information about COVID-19 amplifies compliance with stay-at-home orders. 30 From a logistic regression analysis in North London, non-adherence to all social distancing rules had a stronger association with vulnerability to COVID-19. It is recommended that people living in high-risk environments, should be specially supported when asked to stay at home, and public health messaging should emphasize shared responsibility and public consciousness. 31 Also, our study results underline that the COVID-19 response management in South Kivu applied necessary mitigation actions regarding the surveillance, detection, treatment, and recovery of the pandemic. Although, Awareness and community engagement activities were ineffective. Policy makers across the world have implementing a range of interventions to promote adoption to COVID-19 mitigating measures, which contained elements of education, persuasion, incentivisation, coercion, environmental restructuring, restriction and enablement. Therefore, interventions have been developed rapidly and could not be informed directly by evidence, given the novelty of the virus and rapid spread of the pandemic. 32 Respondents' views on the constraints to implementing COVID-19 restrictive measures ranged from economic means to compliance with, for example, containment, to low awareness of the overall secondary impact of COVID-19, to cultural influences such as the belief that prayers can prevent COVID-19 rather than mitigating measures, etc. A qualitative interview study has shown that, barriers to compliance included inconsistent rules, caring responsibilities, fatigue, unintended consequences of control measures, and the need for emotional support. Facilitators were informational support and social responsibility. 33 During the first wave of the COVID-19 epidemic, while the perceived better-resourced systems of Asia, America and Europe were coping with high mortality due to COVID-19, the first cases of COVID-19 in Africa were followed by predictions of high mortality due to a deficient health system. This led to a strong psychosis among the population and slogans saying that “the disease sent by the white man” and “the disease imported from the white man” would exterminate Africans. Global projections had so far incorrectly predicted large numbers of COVID-19 cases in Africa and that its health systems would be overwhelmed. However, lockdown measures posed considerable economic costs and deleterious effects on cultures, health and behaviors. Consequently, there has been great interest in lockdown exit strategies that preserve lives while protecting livelihoods. 34 Thirdly, we have presented the respondent business opinions on the emergence of COVID-19 and the cultural and religious labeling given to the pandemic. The mains opinions of people in line with the conspiracy and business view of COVID-19 is from one side the epidemic is a business opportunity for country authorities to earn money from international partners and from the other side the fraudulent increases of COVID-19 cases and deaths. This perception has leaded people fearing going to hospital assuming they will be killed to inflate mortality and increased cross contamination in community. Kinga Bierwiaczonek and al . brought out that conspiracy theories about the origins of COVID-19 have been largely spread and have even been propagated by highly ranked state officials and politicians. Their multivariate growth curve analyses showed that, although conspiracy beliefs decreased and social distancing increased over time. 35 Moreover, believing in and being confronted with a COVID-19 conspiracy theory decreased institutional trust, support of governmental regulations, adoption of physical distancing, and to some extent social engagement. 36 Also an example of the cultural and religious labeling is the opinion that the population thinks that COVID − 19 is a satanic disease, for example because of the closing of the churches, but the markets were keeped working. Aysegul and Medeiros have demonstrated that cultural attributes do account for some of the global disparities in COVID-19-attributed health outcomes. As a consequence, policymakers should more explicitly consider a society's cultural attributes in order to develop better tailored and more effective policy responses. 37 A community based study on prevention of COVID-19 among Religious Clerics and Traditional Healers in Ethiopia found that the majority of the participants had poor practice and negative attitudes. Therefore, there should be a sensitization program to fill the gap. 38 Kosarkova and al. , findings showed associations of spirituality and religious fundamentalism with religious conspiracy theories about COVID-19 vaccination. Furthermore, spirituality was linked to a higher possibility of vaccine refusal. 39 A cross sectional study conducted during COVID-19 noted that religion was associated with the frequency of interactions, perceptions of the duration of the social distancing measures, changes in emotional state and history of psychological illness . 40 Moreover, it’s raised from the stakeholder’s opinions, the perspective for self-reliance in the strategies and resources in health risk management. In this regard, the analyze emphasis on the key role of stakeholders from the south in the dialog for change aiming at self-reliance in the health risk communities’ perceptions, strategies and resources. The mains challenges in the health sector in Africa identified Obinna and al., were inadequate human resources, inadequate budgetary allocation to health and poor leadership and management. The leading solutions proposed included training and capacity building for health workers, increase budgetary allocation to health and advocacy for political support and commitment. 41 It cautions that it might not be possible to adequately implement those solution without a concerted fight against corruption, sustained domestic and external investment in social sectors, and enabling macroeconomic and political environment. 42 6 Conclusion The dynamics in attitudes observed within the community brings out the challenges of community engagement in the context of COVID-19. The response to COVID-19 has resulted in the need to apply restrictive measures that have required a behavioral change in the population. Therefore, investigating the perceptions and determinants of implementation of restrictive measures is a good approach. However, to ensure these elements bring added value to the implementation of the health risks response, they should be integrated on the basis of a participatory consultation considering the resources available in the management program. Our bottom-up investigations findings present and discuss entry points for promoting adherence to COVID-19 control measures. Perceptions of COVID-19 as a white man's disease, conspiracy theory and business theory from the community are highlighted. These perceptions arise mainly from the experience of non-transparent management of some previous crises, funded by NGOs and where the community does not perceive their benefits. Nevertheless, cases of increased spread of the COVID-19 and mortality have led to a greater acceptance of the disease risk. Response program authorities should develop two- way communication channels to integrate population expectations, constraints to implementing response measures, information needs. In line with the “utilitarism justice” and “ethics of the health risk response”. We argue that when the health response requires control measures that restrict fundamental freedoms, response strategies must move from the Ministry of Health offices to the field where the community considers itself to be an expert in its own situation. During the first wave of COVID-19, informants pointed to self-reliance in views of health program partnerships. The insights from our study consider that Southern actors have the key role to undertake change. And the major driver is the mobilization and efficient allocation of local resources and initiatives. The health institutions seem to prioritize external aid and strategies recommended by international agencies. Community actors have the same posture, they attack actions in partnership with international agencies mainly because they perceive that NGO actors are better treated compared to the income of the state agencies employees. Without the awareness of the community on the impacts of NGOs, they will not be significant adherence to the actions they undertake in the community. Declarations Ethics approval and consent to participate This study received ethical clearance from the Ethical Committee of the Official University of Bukavu. All methods were performed in accordance with the relevant guidelines and regulations. Written/oral informed consent was obtained from all the participants. Consent for publication Not applicable Clinical trial number Not applicable Competing interests The authors declare that they have no competing interests. Funding None Author Contribution C.A.I. has designed the work, interpreted the data and applied per review revisions. P.K.B. has collected the data and interpreted the data. E.E.G., J.B.M., N.F.C. and, M.R.B. have collected the data. B.Z.A and F.B.R. have applied per review revisions. N.A.M. and Y.C. have drafted the work and revisited it. All authors have reviewed and approved the final manuscript. Acknowledgement We acknowledge the scientific support from the team of the following institutions : BEBUC Program, CEGEMI of UCB and IRG-PH of UB. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on request. References World Health Organization. Communication du risque pendant les urgences sanitaires Communication du risque pendant les urgences sanitaires. 2018. Available on: https://apps.who.int/iris/handle/10665/272269 Red Cross. Volunteers attacked during Ebola burial. 2018. Available on: https://reliefweb.int/report/democratic-republic-congo/dr-congo-red-cross-volunteers-attacked-during-ebola-burial?gclid=EAIaIQobChMIzsSn84yI_gIVghWLCh3AxgZtEAMYASAAEgI-TfD_BwE World Health Organization. Risk communication and community engagement (RCCE) readiness and response to the 2019 novel coronavirus (2019-nCoV): interim guidance. 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Bukavu","correspondingAuthor":false,"prefix":"","firstName":"Marcel","middleName":"Rhushenge","lastName":"Bahizire","suffix":""},{"id":469789537,"identity":"1c6f773f-64b5-49cc-8166-a81967a2b864","order_by":8,"name":"Nicolas Antoine-Moussiaux","email":"","orcid":"","institution":"Department of Public Health Sciences, Université de Liège","correspondingAuthor":false,"prefix":"","firstName":"Nicolas","middleName":"","lastName":"Antoine-Moussiaux","suffix":""},{"id":469789538,"identity":"38174978-5605-407d-a969-21ae807c4ecf","order_by":9,"name":"Yves Coppieters","email":"","orcid":"","institution":"School of Public Health, Université de Bruxelles","correspondingAuthor":false,"prefix":"","firstName":"Yves","middleName":"","lastName":"Coppieters","suffix":""}],"badges":[],"createdAt":"2025-03-13 03:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6215975/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6215975/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84541536,"identity":"418f1c8f-6eff-411e-a1b4-30a148f350ae","added_by":"auto","created_at":"2025-06-13 08:29:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1182613,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6215975/v1/5c0a7e9c-bbc7-424e-be06-b86ba2a16893.pdf"},{"id":84540644,"identity":"2972102a-4ee5-46d4-9831-a532136bca9b","added_by":"auto","created_at":"2025-06-13 08:21:07","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20556,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-6215975/v1/b80dacab01b0c7e8aad7c48e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Organisational learning from community feedbacks on COVID-19 restrictive measures and health management self-reliance perspectives: a socio-anthropological case study in Bukavu, DRCongo","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eEstablishing strategies to respond to emerging diseases is a complex challenge in fragile system contexts with inadequate capacity in health security and surveillance and preparedness for major health emergencies. The nature of the risk in emerging diseases, such as the COVID-19 pandemic, requires well-coordinated health response strategies: crisis management must be reactive, based on a constantly updated situation analysis, prospective modeling, and feedback.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIndeed, the risk communication and community engagement (RCCE) is one of the pillars of engagement in epidemic response. This is because individuals and communities remain the primary actors and decision makers in efforts to promote individual and collective actions related to prevention and response.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e According to the World Health Organization (2020), RCCE is about transparent communication to the public about what is known about the epidemic, what is not known and what is being done. Then, announcing any changes in the response strategy as well as interventions in preparation. It is also about communicating with empathy in local languages and considering cultural values.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In addition, it is important to disseminate up-to-date and useful health advice through reliable communication channels, and then to check how the messages are interpreted by the communities.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e It is therefore recommended that systems be put in place to detect and respond to expectations, rumors and misinformation.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003eFor example, the \"Ebola kills\" message during the RDC\u0026rsquo;s Ebola outbreaks declared in August 2018 led people to believe that the disease was incurable. People then chose to die at home rather than go to treatment centers, which contributed to the spread of the disease. \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Similarly, messages regarding the COVID-19 pandemic should be tested to ensure that they are clear and do not cause unwanted behavioral changes.\u003c/p\u003e \u003cp\u003eAs in several countries in the South, the DR Congo has developed a multisectoral strategic plan against the COVID-19 epidemic that is anchored in the country's health system and is in line with the control strategies proposed by the WHO.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e The analysis of the situation that justifies this investigation is the fact that after the experience of the COVID-19 crisis, several evidences show that the community context of the city of Bukavu has had an adverse impact on the progress of the COVID-19 response. Several points can be raised from the documents consulted. In some cases, the coordination of the response has been hampered by a failure to mobilize the community in the response. One illustrative case is the resignation of Nobel Prize 2018 winner Dr. Mukwege, one of the leaders of the response, an actor who was trusted by the population. Also, there have been reports of contradictions in communication between the national and regional levels of management of COVID-19\u003csup\u003e6,7\u003c/sup\u003e. In addition, the methods used to incentivize the adoption of the response measures would have weakened the participation of the population. As well, we have witnessed demonstrations of denial by the population of the existence of cases of COVID-19 as well as collective refusal marches of barrier measures such as in the commune of Ibanda (Major Vangu venue) and Bagira (Makoma venue) in Bukavu Town.\u003c/p\u003e \u003cp\u003eFor organizational learning, it is necessary to analyze the cases of resistance and non-compliance with COVID-19 response measures. For this study, the aim is to analyze the perceptions and practices of the population in the context of the city of Bukavu, in the province of South Kivu, in DR Congo. South Kivu is identified^ as one of the poorest provinces in the country alongside Equateur and Bandundu: almost six out of seven inhabitants live below the poverty line\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. South Kivu, like most of the DRC's provinces, suffers from inadequate infrastructure and of health personnel. This region has a considerably high morbidity and mortality rate of infectious diseases such as malaria, cholera, tuberculosis, respiratory infections, diarrheal diseases, etc.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e It is this situation of a fragile health system that should face the COVID-19 pandemic. Using a socio-anthropological survey and a literature review this paper provides a retrospective community feedback and perceptions on the first wave COVID-19 restrictive measures in Bukavu city, South Kivu, Democratic Republic of the Congo.\u003c/p\u003e"},{"header":"2 Objectives","content":"\u003cp\u003eThe objective of the investigation is to contribute to describe, through a socio-anthropological study, the different socio-economic and cultural perceptions that represent obstacles or enabling factors to the adherence of the population to the restrictive COVID-19 measures, in South-Kivu, DR Congo.\u003c/p\u003e"},{"header":"3 Materials and methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study environment\u003c/h2\u003e \u003cp\u003eThis research was conducted in Bukavu city located in the Province of South Kivu in Eastern DR Congo between April and July 2020. This province covers an area of 44.90km2, with an estimated population of 1,514,282, and it is a region where living conditions require resilience to the impacts of decades of armed conflict and political and economic instability. The population of the region has adapted to live in conditions of social and economic imbalance due to rural exodus, loss of investment, and weakened educational and health infrastructure. Also, the conditions of imbalance are maintained by the insufficiencies in the governance of public services. On the other hand, decades of political and security instability have led to a severe economic recession. The decline in GDP per capita during this period was 27 percent. Thus, human development indicators deteriorated. The emergence of COVID-19 in this same context, as well as the application of COVID-19 restrictive contingency measures, led as a result to additional social disruptions and losses of substantial income resources. These weaknesses in the system may have posed threats to the community's commitment to the restrictive measures of the COVID-19 response.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Design of the study\u003c/h2\u003e \u003cp\u003e \u003cb\u003eData collection methods and interview guide\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFor conducting this case study, we have used a socio-anthropological investigation\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and a literature documentation for discussion \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The investigation was conducted in the 3 communes of the city of Bukavu between April and July 2020. For the sampling method, the interviewed actors were selected through convenience sampling\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. First, they were selected based on their availability and willingness to participate in the study. Also, the informants were targeted according to the information we aimed to collect from them in relation to either their professional expertise, their personal experiences of the COVID-19 crisis and their educational and social levels. The sample size were realized with the data collected saturation (redundancy of data provided by respondents).\u003c/p\u003e \u003cp\u003eData collection procedure consisted on the one hand, an exploratory survey conducted with key participants including academics, health professionals including technical agents of the COVID-19 response and community members. The objective of the exploratory survey was to involve these stakeholders in the study design\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. They were consulted in order to (i) validate the objectives, (ii) adapt the interview guide, (iii) target the people to be interviewed, and (iv) determine the expectations of the stockholders with regard to the investigation. On the other hand, an in- depth investigation was made by organizing semi-structured interviews and 5 focus group discussions with 86 participants (Table\u0026nbsp;1) to make analysis how the attidudes of these different menbre of the population could influence the adoption to COVID-19 measures (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. We have used an interview guide with open question. The theme explored during the individual interview and focus group discussion was the community perception on restrictive COVID-19 measures and behaviors risks; and the factors that represent obstacles to the adoption of the response measure. The Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e present the detailed themes and sub-themes explored in the interview guide.\u003c/p\u003e \u003cp\u003eThe interview recordings were translated and transcribed. We used the thematic analysis method\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and inductive analysis of qualitative data\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e to progressively present and discuss the survey results by identifying recurring themes in the data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Ethical considerations\u003c/h2\u003e \u003cp\u003e Because this study involves humans, the study respondents have given verbal free and informed consent to participate to the study. They were also consulted for their permission to record the interviews. During field data collection, local traditions, folk customs, norms and values have been respected. Also, the ethical principles of respect for persons, respect for the interests of the respondent́, justice, and respect for communities have been observed. The study was approved by the ethical committee of the Official University of Bukavu, Bukavu, Democratic Republic of the Congo.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Results","content":"\u003cp\u003e\u003cstrong\u003e4.1 \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eBrief description\u003c/strong\u003e \u003cstrong\u003e\u0026nbsp;of the DRC\u0026nbsp;\u003c/strong\u003eCOVID\u003cstrong\u003e\u0026nbsp;-19 response plan\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe notification of the first case of COVID -19 called on the government, with the support of its partners, to develop a strategic plan for the response to COVID 19. Together, they set out to reframe a multisectoral plan against the epidemic to ensure an effective response. In general, the objective was to contribute to interrupting the transmission of \u0026nbsp; COVID -19 and minimizing its health and socio-economic impact throughout the DRC for a period of 12 months. \u0026ldquo;In DRC Congo, experiences from the 10th Ebola outbreak were capitalized on at several levels including coordination, laboratory and case investigation, medical management, infection prevention and control, and community engagement and logistics. At the community engagement level, which is one of the most important steps, certain strategies were developed, including the development of key messages, rumor management, production and dissemination of communication tools, awareness raising, advocacy, and the use of the green line. The strategic plan was then supported by the humanitarian response plan. It describes the humanitarian needs and the response to be implemented to assist the most vulnerable people affected directly or indirectly by the epidemic\u0026rdquo;\u003csup\u003e17\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eInformation about the study participants and theme explored\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTableau 1. Characteristics of respondents interviewed\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 128px;\"\u003eProfession/Occupations\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 175px;\"\u003eNumbers\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 234px;\"\u003eCommunes in Bukavu Town\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003eM \u0026nbsp; \u0026nbsp;Male\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003eFE \u0026nbsp; Female\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003eBagira\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003eKadutu\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003eIbanda\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eUnformal Drug Sellers\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eStudents\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e9\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e5\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e7\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eSmall shopkeepers\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e10\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eHousehold responsible\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e6\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eState Health workers\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eUnemployed youth\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e7\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e6\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eClinical healthcare providers\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e5\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e7\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eHousewives\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e10\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eAdults with no schooling\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e5\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eLawyers\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eClinical healthcare providers in the\u0026nbsp;COVID-19 treatment center\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003eTotal\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e50\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e36\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e24\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e27\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e35\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Themes explored\u003c/strong\u003e \u003cstrong\u003e\u0026nbsp;in the interview guide\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 summarize together the questions formulated prior to data collection. On the other hand, it presents the main sub-themes formulated from the opinions collected during the interviews. The sub-themes derived from the interviews represent the experiences of the participants in the study and will mainly be the object of analysis and discussions.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 713px;\"\u003eThemes prior to data collection\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\u003cstrong\u003e\u003cem\u003eThemes\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003ePerceptions of\u003cbr\u003eCOVID-19\u003cbr\u003eResponse management\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003eCOVID-19 response measure practices\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003eKnowledge and perception of COVID -19 diseases\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003ePerception of restrictive COVID -19 control measures\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\u003cstrong\u003e\u003cem\u003eSub-\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003ethemes\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003ePositive and negative aspects of \u0026nbsp;COVID-19\u003cbr\u003eresponse\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e-COVID\u0026nbsp;19 response measure problems\u003cbr\u003e-Contrast of\u0026nbsp;compliance\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e-Exitance \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-Recognitions\u003cbr\u003e-Treatment and prevention\u003cbr\u003eimpact\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e-Mask wearing -Hand sanitizer use\u003cbr\u003e-Confinement\u003cbr\u003e-Lockdown\u003cbr\u003e-Travel restrictions\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 713px;\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Data \u0026nbsp;sub-themes and discussion elements\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\u003cstrong\u003e\u003cem\u003eSub-themes\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e- Necessary mitigation actions applied\u003cbr\u003e-Ineffective Awareness and community engagement\u0026nbsp;\u003cbr\u003e- Self-reliance\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eneed for health strategies and resources\u003cbr\u003e- Transparency gap in epidemiology reporting\u003cbr\u003e- Involvement of communities in the decision requirement\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e-Main constraint are low\u0026nbsp;economic means,\u003cbr\u003ecommunity \u0026nbsp;awareness gaps,\u003cbr\u003eside cultural influences, etc.\u003cbr\u003e- Community expectations and suggestions: \u0026nbsp;subsidies for protection and testing materials, etc.\u003cbr\u003e-\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eCommunity need of\u0026nbsp;information: symptoms, curative treatments,\u003cbr\u003edifferences\u0026nbsp;between\u0026nbsp;the\u0026nbsp;races,\u003cbr\u003emaximum\u0026nbsp;duration\u0026nbsp;of\u0026nbsp;the\u0026nbsp;crisis,\u003cbr\u003eidentity\u0026nbsp;of\u0026nbsp;the\u0026nbsp;of\u0026nbsp;people\u0026nbsp;affected\u0026nbsp;.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e-Incidence of the COVID-19 pandemic\u003cbr\u003e-Conspiracy theory and business views\u003cbr\u003e-Pandemic Cultural and religious labeling\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e- Measure are important\u003cbr\u003e-Social\u0026nbsp;distancing difficult\u0026nbsp;to\u0026nbsp;apply\u003cbr\u003e-Confinement is impossible\u0026nbsp;\u003cbr\u003e-\u0026nbsp;Application of well-structured incentives required\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\u003cstrong\u003e\u003cem\u003eDiscussion\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e- Increasing acquisition information about COVID-19 amplifies compliance.\u003csup\u003e20\u003c/sup\u003e\u003cbr\u003e-Health sector challenges: inadequate human resources, inadequate budgetary allocation to health and poor leadership and management.\u003csup\u003e41\u003c/sup\u003e\u003cbr\u003e-Sustained domestic and external investment.\u003csup\u003e42\u003c/sup\u003e\u003cbr\u003e- Compliance facilitators in COVID-19 crises are informational support and social responsibility.\u003csup\u003e33\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e-Barriers to compliance included inconsistent rules, caring responsibilities, fatigue, etc.\u003csup\u003e33\u003c/sup\u003e\u003cbr\u003e - Compliance was lower for people who lacked the practical capacity to follow the COVID-19 measures.\u003csup\u003e26XX\u003c/sup\u003e\u003cbr\u003e- Social-distancing compliance is higher when combining with economic and fiscal interventions.\u003csup\u003e30\u003c/sup\u003e\u003cbr\u003e\u003csup\u003e_\u0026nbsp;\u003c/sup\u003eSpirituality was linked to a higher possibility of COVID-19 vaccine refusal.\u003csup\u003e39\u003c/sup\u003e\u003cbr\u003e-Religion was associated with the frequency of interactions\u003cbr\u003eagainst social distancing measures.\u003csup\u003e40\u003c/sup\u003e\u003cbr\u003e-Consider a society\u0026apos;s cultural attributes effective policy responses.\u003csup\u003e37\u003c/sup\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e-Misuse of epidemic response funds in DRCongo.\u003csup\u003e22\u003c/sup\u003e\u003cbr\u003e-Fight against corruption in health sector\u003csup\u003e42\u003c/sup\u003e\u003cbr\u003e-Religious Clerics\u003cbr\u003ehad poor COVID-19 practice and negative attitudes.\u003csup\u003e38\u003c/sup\u003e\u003cbr\u003e- conspiracy theory decreased institutional trust, adoption of physical distancing, and social engagement.\u003csup\u003e36\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e-Interventions \u0026nbsp;developed rapidly and could not be informed directly by evidence.\u003csup\u003e32\u003c/sup\u003e \u003cbr\u003e-Self-interest and health concerns motivated compliance in COVID-19.\u003csup\u003e28\u003c/sup\u003e\u003cbr\u003e- Self-discipline did not work for everyone\u003csup\u003e26XX\u003c/sup\u003e\u003cbr\u003e-\u003csup\u003e\u0026nbsp;\u003c/sup\u003eLockdown measures may have helped inhibit community transmission\u003csup\u003e29\u003c/sup\u003e\u003cbr\u003e-Lockdown posed considerable economic costs and deleterious effects on cultures.\u003csup\u003e34\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e4.2 Common perceptions of COVID -19: between denial of the existence of the COVID -19, socio-financial influences, the importance of barrier measures and the population\u0026apos;s risk behavior\u003c/p\u003e\n\u003cp\u003eIn \u0026nbsp;Africa, \u0026nbsp;and \u0026nbsp;particularly \u0026nbsp;in \u0026nbsp;the \u0026nbsp;DRC, epidemics are \u0026nbsp;not \u0026nbsp;new \u0026nbsp;phenomena. Since the tintroduction \u0026nbsp;of \u0026nbsp; Vibrio cholera in 1974, countries have experienced recurrent epidemics every year. Many of these are related to the increased mobility of goods and people who have been in intercontinental contact. Other epidemics such as malaria, meningitis and measles are water-related and often regular in areas where they are endemic\u003csup\u003e18\u003c/sup\u003e . When the COVID-19 pandemic emerged in Wuhan province in China in November 2019\u003csup\u003e19\u003c/sup\u003e, various perceptions fueled by rumors were heard in the city of Bukavu that impacted the acceptability of the response measures to COVID-19. Until the announcement of the first case in Bukavu, \u0026nbsp;rumors changed with each passing day and gained space for debate. The origin of the disease seemed dark to most of the population. Despite the fact that reliable scientific experiments explain the source of COVID-19, some people were indignant about the situation while others relied on their personal beliefs. This is why, in order to understand the perceptions of the population of Bukavu (Table 3), it is important to question the public discourse and the hidden or backstage discourse.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable3: Perceptions of COVID-19\u003c/strong\u003e \u003cstrong\u003e, the response management and the restrictive measures\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\u003cstrong\u003eSub-themes\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003eCommunity opinions\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\u003cstrong\u003eIncidence of the\u0026nbsp;\u003c/strong\u003eCOVID\u003cstrong\u003e-19\u0026nbsp;pandemic\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e- Uncertain existence due to the lack of tangible evidences\u003cbr\u003e- Coming from the \u0026ldquo;White people\u0026rdquo;.\u003cbr\u003e- Surprise and anxiety following the appearance of COVID 19\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003eConspiracy theory\u0026nbsp;and business\u0026nbsp;views\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e- Existence of COVID\u0026nbsp;-19 but prevalence data are increased by the authorities\u003cbr\u003e- People are fearing going to hospital for fear of being killed, they prefer the treatment from home that increase the contamination\u003cbr\u003e- A business for the authorities to earn money\u003cbr\u003e- COVID Montage, COVID Business, COVID-COP, \u0026quot; Handing over and taking over between Ebola and\u0026nbsp;COVID\u0026nbsp;-19 \u0026quot;.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\u003cstrong\u003eCultural and religious labeling\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e- The population thinks that COVID -19 is a satanic disease, for example because of \u0026nbsp;the closing of the churches, but the markets are working\u003cbr\u003e- \u0026quot;Hair between the pages of the Bible\u0026quot; is put in water as a medicine\u003cbr\u003e- Closing the churches is a good measure, but it has lasted many months already\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\u003cstrong\u003eUnderstanding of the scientific nature of COVID-19\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e- Disease that emerged from China\u003cbr\u003e- A zoonosis transmitted by either pangolin or snakes\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003eResponse measures: Confinement, \u003cem\u003eHand sanitizer use,\u0026nbsp;\u003c/em\u003emask wearing, hand washing, social, etc.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e- Are good and effective if they are respected\u003cbr\u003e- Do not agree with closing schools and churches as well as confinement\u003cbr\u003e- Confinement is impossible given the low socio-economic means and it would be good if the State helped people to survive\u003cbr\u003e- Social distancing is a good measure but difficult to apply in our context\u003cbr\u003e- Hand washing: good measure against COVID-19 and other diseases\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003eManagement \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;of \u0026nbsp;COVID-19 in South Kivu\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e- Good because there are those who heal\u003cbr\u003e- Bad because some hospitals charge for the treatment of this disease\u003cbr\u003e- Awareness and community engagement are ineffective\u003cbr\u003e- Communication is ineffective due to lack of trust, awareness, rumors and\u003cbr\u003econtradictions in the response team\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThus, these perceptions can be explained by several elements, including four main ones as revealed by our study:\u003c/p\u003e\n\u003cp\u003ePerceptions about the incidence of the COVID -19 pandemic: \u0026quot;A disease from the Whites\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFirst, when it emerged in the community, COVID-19 has \u0026nbsp;been described as a western \u0026quot;white man\u0026apos;s disease \u0026ldquo;that can only kill whites, not Africans. When the virus had already spread with great morbidity all over the world, with the exception of several African countries, it became a way to make assumptions that would justify it. On the one hand, at the international level, some scientists put forward the hypothesis that Africa will not be much affected due to its geographical position dominated by the warm climate, the virus would not be resistant there. Others have shown that the organism of the Africans used to the regular consumption of anti-malaria drugs strengthens its humility. In addition, it has been hypothesized that Africa has a predominantly young population, so that COVID -19 would directly attack the elderly and others with co-morbidities\u003csup\u003e9\u003c/sup\u003e. While the above perceptions are not the same as what said, the World Health Organization Director General Tedros Adhanom Ghebreyesus : \u0026ldquo;the best advice for Africa is to prepare for the worst and to prepare today \u0026quot;\u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eA \u003cstrong\u003e\u003cem\u003eHousewives\u003c/em\u003e\u003c/strong\u003e told us:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;(...) this is one more misery in our life and it comes from the Occident among the Whites because we didn\u0026apos;t know that such a tragedy was going to happen to us, the children don\u0026apos;t study anymore, and those who have studied don\u0026apos;t have jobs...\u0026quot;.\u0026nbsp;\u003c/em\u003e(extract from an interview with a Housewives, Bukavu-DRC, April 2020),\u003c/p\u003e\n\u003cp\u003eThe emergence of COVID-19: the business views\u003c/p\u003e\n\u003cp\u003eSecondly, COVID-19 is perceived to be a human invention, a \u0026quot;white man\u0026apos;s invention\u0026quot;, manufactured in a European laboratory. In the same logic, it is also considered as a biological weapon against some states of the world, especially those in political and economic conflicts. Talking about a human invention for epidemics is not a first in the history of epidemics in the DRC. During the Ebola epidemic in eastern DR Congo that was declared in August 2018, it was one of the forms of misinformation that led communities to strongly resist humanitarian response actions. A similar situation was observed during the vaccination activities where at the time, some households resisted the vaccination of their children. On the one hand, populations are insufficiently informed or sensitized, on the other hand, vaccines are considered experimental and have negative effects such us the Ebola vaccines \u0026nbsp; ChAd3-SUDV, CAdOx1 and \u0026nbsp;SV-SUDV\u003csup\u003e21\u003c/sup\u003e. All of this leads the population to rely much more on the different misinformation circulating in the environment and which have rarely been contradicted by the specialized body in communication and listening.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The cultural and religious labeling of the pandemic\u003c/p\u003e\n\u003cp\u003eThird, COVID 19\u0026nbsp;is\u0026nbsp;perceived as\u0026nbsp;a\u0026nbsp;punishment\u0026nbsp;from\u0026nbsp;God\u0026nbsp;(divine\u0026nbsp;punishment)\u0026nbsp;or\u0026nbsp;\u0026quot;Pigo\u0026nbsp;la\u0026nbsp;Mungu\u0026quot;\u0026nbsp;in\u0026nbsp;Swahili.\u0026nbsp;It\u0026nbsp;is\u0026nbsp;in\u0026nbsp;the\u0026nbsp;sense that\u0026nbsp;it\u0026nbsp;has\u0026nbsp;attacked\u0026nbsp;the\u0026nbsp;whole\u0026nbsp;world\u0026nbsp;as\u0026nbsp;a\u0026nbsp;result\u0026nbsp;of\u0026nbsp;the\u0026nbsp;extreme\u0026nbsp;sins\u0026nbsp;of\u0026nbsp;men on earth.\u0026nbsp;Some\u0026nbsp;the\u0026nbsp;people\u0026nbsp;from\u0026nbsp;Bukavu, God\u0026nbsp;has\u0026nbsp;revealed\u0026nbsp;himself\u0026nbsp;and\u0026nbsp;acted as\u0026nbsp;in\u0026nbsp;the\u0026nbsp;ancient times\u0026nbsp;when\u0026nbsp;he\u0026nbsp;punished through\u0026nbsp;acts\u0026nbsp;and\u0026nbsp;words.\u0026nbsp;In\u0026nbsp;Bukavu, some church representativess had recuperated the discourse of the population by certifying God\u0026apos;s share of the responsibility for COVID-19. Through the radio programs that they hosted, most\u0026nbsp;of the preaching revolved around\u0026nbsp;the\u0026nbsp;pandemic,\u0026nbsp;with\u0026nbsp;the\u0026nbsp;posture\u0026nbsp;of\u0026nbsp;proving\u0026nbsp;to\u0026nbsp;Christians\u0026nbsp;the\u0026nbsp;wrath\u0026nbsp;of\u0026nbsp;God\u0026nbsp;so\u0026nbsp;that\u0026nbsp;they\u0026nbsp;would\u0026nbsp;repent.\u0026nbsp;A resident\u0026nbsp;of\u0026nbsp;the\u0026nbsp;commune\u0026nbsp;of\u0026nbsp;Kadutu\u0026nbsp;said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;There was a time when a preaching was circulating on social networks through which an evangelist claimed to have had a revelation from God regarding COVID 19. The so-called God-Man said that God revealed to him the medicine to cure COVID -19 and that it was simple. All you have to do is to have a bible and open it to look for a hair to put in a glass of water and drink in order to heal and not to get COVID-19 anymore. I assure you, many people believed in this and did not hesitate to do it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(extract from an interview with an inhabitant of the commune of Kadutu, Bukavu/DRC, May 2020).\u003c/p\u003e\n\u003cp\u003eAnother continues:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;At\u0026nbsp;the\u0026nbsp;beginning,\u0026nbsp;people\u0026nbsp;talked\u0026nbsp;about\u0026nbsp;the\u0026nbsp;\u0026quot;Hair\u0026nbsp;of\u0026nbsp;the\u0026nbsp;Bible\u0026quot;.\u0026nbsp;People\u0026nbsp;started\u0026nbsp;to\u0026nbsp;look\u0026nbsp;for\u0026nbsp;hair\u0026nbsp;in\u0026nbsp;the\u0026nbsp;bible that\u0026nbsp;they\u0026nbsp;would\u0026nbsp;put\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003edown\u0026nbsp;to\u0026nbsp;drink\u0026nbsp;to\u0026nbsp;protect\u0026nbsp;themselves\u0026nbsp;from\u0026nbsp;COVID-19.\u0026rdquo;\u003c/em\u003e (extract from an interview with COVID-19 response committee staff, Bukavu/DRC, May 2020).\u003c/p\u003e\n\u003cp\u003eIn addition, there is also the habit of the population to be regularly in contact for family, religious, commercial activities, etc. has constituted a barrier for the COVID-19 measures as social distancing. In\u0026nbsp;the\u0026nbsp;city\u0026nbsp;of\u0026nbsp;Bukavu,\u0026nbsp;the\u0026nbsp;evidence\u0026nbsp;of\u0026nbsp;the\u0026nbsp;non- adoption\u0026nbsp;of\u0026nbsp;measures\u0026nbsp;has\u0026nbsp;been\u0026nbsp;multiple\u0026nbsp;and\u0026nbsp;is\u0026nbsp;manifested\u0026nbsp;through\u0026nbsp;the\u0026nbsp;mis\u0026nbsp;respect\u0026nbsp;of\u0026nbsp;confinement,\u0026nbsp;isolation\u0026nbsp;and social\u0026nbsp;distancing.\u0026nbsp;In\u0026nbsp;order\u0026nbsp;to\u0026nbsp;survive\u0026nbsp;the\u0026nbsp;socio-economic\u0026nbsp;conditions,\u0026nbsp;people\u0026nbsp;are\u0026nbsp;forced\u0026nbsp;to\u0026nbsp;distrust\u0026nbsp;these\u0026nbsp;measures while\u0026nbsp;the\u0026nbsp;government\u0026nbsp;fails\u0026nbsp;to\u0026nbsp;find\u0026nbsp;alternatives\u0026nbsp;to\u0026nbsp;provide\u0026nbsp;for\u0026nbsp;its\u0026nbsp;population.\u0026nbsp;A\u0026nbsp;Professor\u0026nbsp;of\u0026nbsp;University\u0026nbsp;says:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;First\u0026nbsp;of\u0026nbsp;all,\u0026nbsp;at\u0026nbsp;the\u0026nbsp;social\u0026nbsp;level:\u0026nbsp;people\u0026nbsp;are\u0026nbsp;used\u0026nbsp;to\u0026nbsp;living\u0026nbsp;together\u0026nbsp;here\u0026nbsp;in\u0026nbsp;the\u0026nbsp;name\u0026nbsp;of\u0026nbsp;African\u0026nbsp;solidarity, when\u0026nbsp;we\u0026nbsp;are\u0026nbsp;forced\u0026nbsp;to\u0026nbsp;confine\u0026nbsp;ourselves,\u0026nbsp;it\u0026nbsp;is\u0026nbsp;really\u0026nbsp;negative\u0026nbsp;compared\u0026nbsp;to\u0026nbsp;our\u0026nbsp;usual\u0026nbsp;life.\u0026nbsp;These\u0026nbsp;are\u0026nbsp;only new\u0026nbsp;habits\u0026nbsp;that\u0026nbsp;have\u0026nbsp;been\u0026nbsp;asked\u0026nbsp;of\u0026nbsp;us:\u0026nbsp;confinement,\u0026nbsp;isolation,\u0026nbsp;quarantine\u0026quot;.\u003c/em\u003e (Extract from an interview with a Professor, Bukavu-DRC, July 2020).\u003c/p\u003e\n\u003cp\u003eCases of community understanding of the scientific nature of COVID-19\u003c/p\u003e\n\u003cp\u003eFourth,\u0026nbsp;beyond\u0026nbsp;the\u0026nbsp;misinformation,\u0026nbsp;there\u0026nbsp;was\u0026nbsp;another\u0026nbsp;part\u0026nbsp;of\u0026nbsp;the\u0026nbsp;population\u0026nbsp;that\u0026nbsp;believed\u0026nbsp;in\u0026nbsp;the\u0026nbsp;existence\u0026nbsp;of\u0026nbsp;the disease.\u0026nbsp;Within\u0026nbsp;their\u0026nbsp;communities,\u0026nbsp;these\u0026nbsp;people\u0026nbsp;showed\u0026nbsp;interest\u0026nbsp;in\u0026nbsp;practicing\u0026nbsp;precautionary\u0026nbsp;measures.\u0026nbsp;In\u0026nbsp;the meantime, they called on those around them to adopt the recommendations of the WHO and the provincial government\u0026nbsp;in\u0026nbsp;charge\u0026nbsp;of\u0026nbsp;public\u0026nbsp;health.\u0026nbsp;A\u0026nbsp;student\u0026nbsp;at\u0026nbsp;one\u0026nbsp;of\u0026nbsp;Bukavu\u0026apos;s\u0026nbsp;universities\u0026nbsp;said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;For me and my family we believed in it and the others took it as a business deal\u0026hellip;\u0026quot;\u0026nbsp;\u003c/em\u003e(extract from an interview with a student, Bukavu-DRC, April 2020).\u003c/p\u003e\n\u003cp\u003eBut in practice, the provincial policy has not made it easy for the population to take ownership of the response activities. In view of all these perceptions linked to misinformation and rumors within the population. Communication and community involvement are important and indispensable in the response to an epidemic due to its danger and contagiousness. The response measures raise socio-economic issues that require community support. Also, listening to the people involved is also one of the components of effective communication. In this context, the radio was the most frequent source of information for the population and for others, information was received in the community through friends, relatives, acquaintances, neighbors, etc. Also, some \u0026nbsp; billboards \u0026nbsp;and \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;posters \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;were \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;used \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;to \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; raise awareness. Furthermore, the technical agents involved in the response showed particular motivation and gave more importance to the application of the response measures. A health worker at the Response Center confided to us:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;...\u0026nbsp;First\u0026nbsp;of\u0026nbsp;all,\u0026nbsp;we\u0026nbsp;must\u0026nbsp;ignore\u0026nbsp;this\u0026nbsp;African\u0026nbsp;solidarity\u0026nbsp;and\u0026nbsp;Christianity\u0026nbsp;and\u0026nbsp;respect\u0026nbsp;the\u0026nbsp;barrier\u0026nbsp;measures first.\u0026nbsp;These\u0026nbsp;are\u0026nbsp;the\u0026nbsp;measures\u0026nbsp;that\u0026nbsp;will\u0026nbsp;allow\u0026nbsp;us\u0026nbsp;to\u0026nbsp;resume\u0026nbsp;our\u0026nbsp;activities\u0026nbsp;as\u0026nbsp;before\u0026nbsp;without\u0026nbsp;any\u0026nbsp;problems.\u0026quot;\u003c/em\u003e (extract from a health care worker at the COVID-19 /Bukavu/Kadutu/DRC Response Center, June 2020).\u003c/p\u003e\n\u003cp\u003e4.3. Community feedback on the response to COVID-19\u003c/p\u003e\n\u003cp\u003eTable 4 summarizes information related to the population\u0026apos;s expectations of the response team, constraints to implementing the response measures, needs to know about COVID-19 and suggestions for response measures formulated by the population of Bukavu city at the start of the pandemic in April 2020.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTableau\u003c/strong\u003e \u003cstrong\u003e\u0026nbsp;4: Population expectations, constraints to implementing response measures, information needs on COVID-19 and suggestions for actions in the response\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 627px;\"\u003eSub-theme\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003eExpectations and suggestions\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003eNeed of\u0026nbsp;informations\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003eConstraints to implement the measures\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003eSubsides application\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e-Installation of \u0026nbsp;taps for hand washing, the distribution of hand sanitizer as well as nose mask\u003cbr\u003e- Communicate identities\u0026nbsp;of\u0026nbsp;the\u0026nbsp;people\u0026nbsp;affected\u003cbr\u003e- The promotion and aid to young entrepreneurs\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e-To know the cost of the COVID-19 treatment\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e- Lack of financial means\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003eResponse management\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e-Carry out the rapid analysis test at the provincial level to avoid sending\u0026nbsp;samples\u0026nbsp;to\u0026nbsp;the\u0026nbsp;capital\u0026nbsp;city\u003cbr\u003e- Publication of \u0026nbsp; \u0026nbsp; \u0026nbsp;the \u0026nbsp; real \u0026nbsp;prevalence\u003cbr\u003e- No lockdown do avoid economic side effect\u003cbr\u003e- Open Churches and maintain public market\u0026nbsp;\u003cbr\u003e- Standardize the treatment over the whole country\u003cbr\u003e- Financial assistance\u0026nbsp;to\u0026nbsp;the\u0026nbsp;population\u003cbr\u003elistening\u0026nbsp;to\u0026nbsp;the\u0026nbsp;population\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e-The\u0026nbsp;maximum\u0026nbsp;duration\u0026nbsp;of\u0026nbsp;the\u0026nbsp;crisis\u003cbr\u003e- Possible resurgence of the epidemic\u003cbr\u003e- To know\u0026nbsp;the\u0026nbsp;symptoms,\u0026nbsp;curative\u0026nbsp;treatments\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e- Disease said to be invented by the politicians as to get funding from international partners\u003cbr\u003e- Misunderstanding\u0026nbsp;between\u0026nbsp;the\u0026nbsp;persons\u0026nbsp;in\u0026nbsp;charge\u0026nbsp;of\u0026nbsp;the\u0026nbsp;response\u003cbr\u003e- Gap in the community engagement activities\u003cbr\u003e- Lack of resources (funds, laboratory equipment, qualified personnel, health risks preparedness strategies, etc).\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003eIncitatives for measures application\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e- Rigor\u0026nbsp;and\u0026nbsp;to\u0026nbsp;convince\u0026nbsp;the population\u0026nbsp;of\u0026nbsp;the\u0026nbsp;existence\u0026nbsp;of\u0026nbsp;the\u0026nbsp;pandemic.\u003cbr\u003e- Strengthen the monitoring\u0026nbsp;\u003cbr\u003eof barrier measures application\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e-To know the existence of \u0026nbsp;differences between the races\u003cbr\u003e-To know the\u0026nbsp;identity\u0026nbsp;of\u0026nbsp;the\u0026nbsp;of\u0026nbsp;people\u0026nbsp;affected\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e- The negligence of mitigation measures\u003cbr\u003e- The lack of belief in the existence of the disease\u003cbr\u003e- Cultural perceptions e.g. COVID is a satanic diseases leading to close churches\u003cbr\u003e- Social interaction (greetings, help, wedding, bereavement, peacebuilding grouping, etc).\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 \u0026nbsp;\u003c/strong\u003eSelf-reliance\u003cstrong\u003e\u0026nbsp;perspectives of strategies and resources in health risk management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFifth,\u0026nbsp;from\u0026nbsp;the interviews, we can\u0026nbsp;raise\u0026nbsp;in\u0026nbsp;the\u0026nbsp;opinion\u0026nbsp;that\u0026nbsp;the\u0026nbsp;importance\u0026nbsp;is\u0026nbsp;more\u0026nbsp;given\u0026nbsp;to\u0026nbsp;the\u0026nbsp;resources\u0026nbsp;coming from\u0026nbsp;the\u0026nbsp;international\u0026nbsp;aid\u0026nbsp;to\u0026nbsp;the\u0026nbsp;detriment\u0026nbsp;of\u0026nbsp;the\u0026nbsp;potential\u0026nbsp;resources\u0026nbsp;and\u0026nbsp;local\u0026nbsp;initiatives\u0026nbsp;in\u0026nbsp;the\u0026nbsp;management\u0026nbsp;of the risks. The same is true of the respondent\u0026rsquo;s\u0026rsquo; prioritization of the application of response strategies recommended by international\u0026nbsp;agencies\u0026nbsp;without\u0026nbsp;much\u0026nbsp;attention\u0026nbsp;to\u0026nbsp;the\u0026nbsp;need\u0026nbsp;to\u0026nbsp;adapt\u0026nbsp;the\u0026nbsp;strategies\u0026nbsp;to\u0026nbsp;the\u0026nbsp;local\u0026nbsp;contexts.\u0026nbsp;This\u0026nbsp;study found\u0026nbsp;several\u0026nbsp;instances\u0026nbsp;where\u0026nbsp;more\u0026nbsp;emphasis\u0026nbsp;is\u0026nbsp;placed\u0026nbsp;by interviewees\u0026nbsp;on\u0026nbsp;prioritizing\u0026nbsp;international\u0026nbsp;assistance.\u0026nbsp;One\u0026nbsp;lawyer\u0026nbsp;told us:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I\u0026nbsp;see\u0026nbsp;for\u0026nbsp;example\u0026nbsp;for\u0026nbsp;Ebola\u0026nbsp;we\u0026nbsp;were\u0026nbsp;talking\u0026nbsp;about\u0026nbsp;Ebola\u0026nbsp;montage,\u0026nbsp;Ebola\u0026nbsp;Business,\u0026nbsp;Ebola\u0026nbsp;business\u0026nbsp;etc.\u0026nbsp;When the coronavirus disease was declared in Kinshasa, it was said that there is a handover\u003c/em\u003e\u003cem\u003e\u0026nbsp;and recovery between Ebola and \u0026nbsp;COVID-19\u0026quot;\u003c/em\u003e (extract from an interview with a lawyer, Bukavu/DRC, May 2020).\u003c/p\u003e\n\u003cp\u003eAccording to student:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The response agents and the government are playing with us to get the funding. As a result, the population has started to disobey the recommendations of the authorities. At my home in Bagira, for example,\u0026nbsp;you\u0026nbsp;have\u0026nbsp;to\u0026nbsp;hide\u0026nbsp;your\u0026nbsp;mask\u0026nbsp;because\u0026nbsp;since\u0026nbsp;the\u0026nbsp;death\u0026nbsp;of\u0026nbsp;a\u0026nbsp;citizen\u0026nbsp;by\u0026nbsp;a\u0026nbsp;police\u0026nbsp;officer\u0026nbsp;following the disrespecting of wearing a nose masks, the population has said to themselves that they should no longer\u0026nbsp;wear\u0026nbsp;them,\u0026nbsp;so\u0026nbsp;that\u0026nbsp;the\u0026nbsp;police\u0026nbsp;would\u0026nbsp;kill\u0026nbsp;all\u0026nbsp;the\u0026nbsp;people\u0026quot;\u003c/em\u003e (extract from an interview with a student in the commune of Bagira, Bukavu/DRC, July 2021).\u003c/p\u003e\n\u003cp\u003eOn the other hand, informants pointed out that the recommendations for managing the pandemic formulated by international organizations are prioritized by \u0026nbsp;the \u0026nbsp; COVID-19 Response organization\u003csup\u003e5\u003c/sup\u003e instead of adapting the strategy to the context. This is the example of the student who said that:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If you tell him to stay at home and in the evening, I will bring you food for the children, I assure you everyone can stay at home. Otherwise, it is not possible. How? and the children? You\u0026apos;re going to tell someone\u0026nbsp;to\u0026nbsp;stay\u0026nbsp;home\u0026nbsp;when\u0026nbsp;they\u0026nbsp;don\u0026apos;t\u0026nbsp;know\u0026nbsp;how\u0026nbsp;to\u0026nbsp;eat?\u0026nbsp;I\u0026nbsp;don\u0026apos;t\u0026nbsp;think\u0026nbsp;that\u0026apos;s\u0026nbsp;humane.\u0026nbsp;Elsewhere,\u0026nbsp;like\u0026nbsp;in France, people have been asked to stay at home, but at least the government gives them subsidies\u0026quot;\u003c/em\u003e (extract from an interview with a student in the commune of Ibanda, Bukavu/DRC, July 2021)\u003c/p\u003e\n\u003cp\u003eFrom this perspective, we can emphasize two situations related to two types of actors. First, the health institutions that remain dependent on external aid for health responses. This is due to the difficulties in mobilizing new resources or allocating existing resources to priority problems in accordance with the health management ethical principle of utilitarian justice. Utilitarian justice stipulates the prioritization of strategies aimed at guaranteeing the well-being of the vast majority of the population. In addition, the \u0026nbsp;poor management of \u0026nbsp;resources allocated to health risk management in general. For example, former DR Congo Health Minister Oly Ilunga Kalenga was condemned to five years of hard labor for the misuse of funds to address Ebola in the east of the country\u003csup\u003e22\u003c/sup\u003e . Indeed, the health sector is an attractive sector for corruption. The availability of foreign aid for health has also fueled corruption globally. Corruption limits access to health services and weakens all the dimensions that determine good health system performance: equity, quality, responsiveness, efficiency, and resilience, and also affects outcomes and lives. It is estimated that the world spends more than US$7 trillion on health services and that at least 10-25% of global spending is lost directly to corruption, amounting to hundreds of billions of dollars lost each year. These billions lost to corruption exceed WHO estimates of the amount needed each year to make up the shortfall to achieve universal health coverage worldwide by 2030\u003csup\u003e23\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSecondly,\u0026nbsp;with\u0026nbsp;regard\u0026nbsp;to\u0026nbsp;the\u0026nbsp;suspicion\u0026nbsp;of\u0026nbsp;misappropriation\u0026nbsp;of\u0026nbsp;funds,\u0026nbsp;the\u0026nbsp;population\u0026nbsp;refers\u0026nbsp;to\u0026nbsp;the\u0026nbsp;embezzlement of funds from international aid and not the country\u0026apos;s own funds that would be allocated to the response. In addition, community actors (referring to the lifestyle of NGO employees) perceive that they are better off compared to the income of the employees of the state agencies. These opinions are reinforced by the lack of information\u0026nbsp;among\u0026nbsp;the\u0026nbsp;population\u0026nbsp;regarding\u0026nbsp;the\u0026nbsp;impacts\u0026nbsp;of\u0026nbsp;NGO\u0026nbsp;projects.\u0026nbsp;This\u0026nbsp;is\u0026nbsp;why\u0026nbsp;public\u0026nbsp;opinion\u0026nbsp;suspects that\u0026nbsp;there\u0026nbsp;is\u0026nbsp;business\u0026nbsp;activity\u0026nbsp;every\u0026nbsp;time\u0026nbsp;a\u0026nbsp;new\u0026nbsp;epidemic\u0026nbsp;emerges.\u0026nbsp;These\u0026nbsp;perceptions\u0026nbsp;constitute\u0026nbsp;an\u0026nbsp;obstacle\u0026nbsp;to the\u0026nbsp;acceptance\u0026nbsp;of\u0026nbsp;the\u0026nbsp;actions\u0026nbsp;of\u0026nbsp;interventions\u0026nbsp;in\u0026nbsp;partnership\u0026nbsp;with\u0026nbsp;NGOs.\u0026nbsp;According\u0026nbsp;to\u0026nbsp;the\u0026nbsp;Quebec\u0026nbsp;association\u0026nbsp;of international\u0026nbsp;cooperation\u0026nbsp;organizations,\u0026nbsp;the valorization of knowledge from the countries of the South and the need to give back to communities\u0026nbsp;the\u0026nbsp;power\u0026nbsp;over\u0026nbsp;their\u0026nbsp;development\u0026nbsp;call\u0026nbsp;for\u0026nbsp;a\u0026nbsp;decolonization\u0026nbsp;of\u0026nbsp;thoughts\u0026nbsp;and\u0026nbsp;practices,\u0026nbsp;in\u0026nbsp;order\u0026nbsp;to establish a true cooperation, fully respectful of the people\u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePartnerships with international health institutions are very beneficial in the development of intervention strategies for epidemic management. Also, these partnerships provide technical, operational and financial support that is very beneficial for some countries in the South with fragile systems in terms of organization of surveillance and prevention of emerging diseases. Nevertheless, as raised in our analysis, there is an increasing prioritization of resources that come from international aid to the detriment of local initiatives. These locals\u0026rsquo; initiatives include national resources (existing and other financial resources that need to be developed) to be used in an appropriate way, human resources that need to be capacitated, disease surveillance and detection plan that needs to be strengthened, etc. From the perspective of self-reliance (Table 5), for autonomy of initiative in the development of health management strategies, there is a great responsibility of health systems in the South. That\u0026rsquo;s to establish risk analysis bodies that are mandated to formulate strategies for action and to contextualize the recommendations of international institutions. In order to have the autonomy to initiate intervention strategies, it is necessary to set up health risk analysis and management bodies. These bodies should be capable of identifying risk agents, selecting toxicological reference values, assessing population exposures, characterizing health risk\u003csup\u003e25\u0026nbsp;\u003c/sup\u003e\u0026nbsp; and generating, evaluating and selecting health risk management options.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTableau 5:\u0026nbsp;\u003c/strong\u003eSelf-reliance \u003cstrong\u003e\u0026nbsp;of strategies and resources for health management\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\u0026nbsp;\u003cbr\u003eResults from interviews\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003eSelf-reliance\u003cstrong\u003e\u0026nbsp;for resources raising\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e- The health institutions that remain dependent on external aid for health emergent responses.\u003cbr\u003e- Difficulties in mobilizing new resources or allocating existing resources to priority problems.\u003cbr\u003e- The poor management of resources allocated to health risk management. Eg. the former Minister of Health of the DR Congo, Oly Ilunga Kalenga, was sentenced to five years of hard labor for\u003cbr\u003eembezzling funds intended for the fight against the Ebola virus\u003csup\u003e22\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003eSelf-reliance for \u003cstrong\u003e\u0026nbsp;strategies development\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e-Prioritization of the application of response strategies recommended\u0026nbsp;by\u0026nbsp;international\u0026nbsp;health\u0026nbsp;organizations\u0026nbsp;without\u0026nbsp;much attention\u0026nbsp;to\u0026nbsp;the\u0026nbsp;need\u0026nbsp;to\u0026nbsp;adapt\u0026nbsp;the\u0026nbsp;strategies\u0026nbsp;to\u0026nbsp;the\u0026nbsp;contexts.\u003cbr\u003e-The\u0026nbsp;responsibility\u0026nbsp;of\u0026nbsp;health\u0026nbsp;systems\u0026nbsp;in\u0026nbsp;the\u0026nbsp;South\u0026nbsp;is\u0026nbsp;to\u0026nbsp;establish\u0026nbsp;risk analysis\u0026nbsp;bodies\u0026nbsp;that\u0026nbsp;are\u0026nbsp;mandated\u0026nbsp;to\u0026nbsp;formulate\u0026nbsp;strategies.\u003cbr\u003e-This bodies should be able of identifying risk agents, selecting toxicological reference values, assessing population exposures,\u003cbr\u003echaracterizing health risk.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003eSelf-reliance\u0026nbsp;about the\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ecommunity\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eperceptions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e- The population refers to the funds from international aid and not the country\u0026apos;s own funds that would be allocated to the response.\u003cbr\u003e- Increasing prioritization of resources that come from international aid to the detriment of local initiatives\u003cbr\u003e- Community actors (referring to the lifestyle of NGO civil servants) perceive that they are better off compared to the income of the Congolese civil service.\u003cbr\u003e- Lack of information among the population regarding the impacts of NGO projects.\u003cbr\u003e- Common opinion suspects that there is business activity every time a new epidemic emerges and NGO partnerships. E.g., an obstacle to the acceptance of the actions of interventions in partnership with NGOs.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"5 Discussion","content":"\u003cp\u003eThis work describes and discusses case lessons from the experience of restrictive measures the COVID-19 epidemic of the population of the city of Bukavu, South Kivu, DRCongo. This case study presents organizational learning opportunities on community feedbacks on COVID-19 restrictive measures and health management self-reliance perspectives from the experience of a small number of community and health members. The results produced provide a solid basis for qualitative studies with a larger number of participants, as well as quantitative studies and statistical analyses to establish relationships between different determinants.\u003c/p\u003e \u003cp\u003eFirst, we have described cases of the community members who had clair understanding of the scientific characteristics of COVID-19. Although these people showed interest in practicing barriers measures, the communication and community participation strategies of the response has not strengthened the community ownership of the response activities. A study on compliance with COVID-19 mitigation measures noted that intrinsic (moral and social) motivations promoted compliance. Yet appeals on self-discipline did not work for everyone, compliance was lower for people who lacked the practical capacity to follow the measures and for those who have the opportunity to break the measures.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Further in line with our results, Benjamin van Rooij and \u003cem\u003eal.\u003c/em\u003e brought to light that compliance COVID-19 restrictive measures depended as well on people\u0026rsquo;s intrinsic motivations, including substantive moral support and social norms.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Also, a study revealed self-interest and health concerns motivated compliance, normative concerns regarding duty to support the authorities dominated compliance decisions in COVID-19 response.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSecondly, our findings draw lessons from community feedback on restrictive COVID-19 measures while enhancing the suggestions that can have a positive influence on compliance. We have enhanced the people expectation and suggestion to enable the compliance such us the transparency in epidemiology report, subsidies of protection and testing materials, application of well-structured incentives, involvement of communities in the decision, etc. Faced with doubts about the existence of COVID-19 cases, many community members have attached importance to the possibility of publishing the identities of people affected in order to reassure themselves. This being impossible in view of the obligation not to violate patient confidentiality, it points to the need for transparency in epidemiological reporting to engage people in the response. A study have described the design of lockdown measures in nine countries in sub-Saharan Africa and fund that while lockdown measures may have helped inhibit community transmission, the pattern and nature of the epidemic remains unclear.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eConcerning restrictive COVID-19 measures, respondents have given particular attention to the perception that Social distancing is a good measure but difficult to apply in our context of Bukavu town and confinement is impossible given the low socio-economic means. The confinement might work if the state helped vulnerable people to survive. Based on a sample of Africa countries findings suggest that compliance with COVID-19 social-distancing is higher in countries applying strict containment measures. Also, people compliance with social-distancing measures is higher when combining lockdown measures with economic and fiscal interventions. We also find that access to the internet or increasing acquisition information about COVID-19 amplifies compliance with stay-at-home orders.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e From a logistic regression analysis in North London, non-adherence to all social distancing rules had a stronger association with vulnerability to COVID-19. It is recommended that people living in high-risk environments, should be specially supported when asked to stay at home, and public health messaging should emphasize shared responsibility and public consciousness.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlso, our study results underline that the COVID-19 response management in South Kivu applied necessary mitigation actions regarding the surveillance, detection, treatment, and recovery of the pandemic. Although, Awareness and community engagement activities were ineffective. Policy makers across the world have implementing a range of interventions to promote adoption to COVID-19 mitigating measures, which contained elements of education, persuasion, incentivisation, coercion, environmental restructuring, restriction and enablement. Therefore, interventions have been developed rapidly and could not be informed directly by evidence, given the novelty of the virus and rapid spread of the pandemic.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRespondents' views on the constraints to implementing COVID-19 restrictive measures ranged from economic means to compliance with, for example, containment, to low awareness of the overall secondary impact of COVID-19, to cultural influences such as the belief that prayers can prevent COVID-19 rather than mitigating measures, etc. A qualitative interview study has shown that, barriers to compliance included inconsistent rules, caring responsibilities, fatigue, unintended consequences of control measures, and the need for emotional support. Facilitators were informational support and social responsibility.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDuring the first wave of the COVID-19 epidemic, while the perceived better-resourced systems of Asia, America and Europe were coping with high mortality due to COVID-19, the first cases of COVID-19 in Africa were followed by predictions of high mortality due to a deficient health system. This led to a strong psychosis among the population and slogans saying that \u0026ldquo;the disease sent by the white man\u0026rdquo; and \u0026ldquo;the disease imported from the white man\u0026rdquo; would exterminate Africans. Global projections had so far incorrectly predicted large numbers of COVID-19 cases in Africa and that its health systems would be overwhelmed. However, lockdown measures posed considerable economic costs and deleterious effects on cultures, health and behaviors. Consequently, there has been great interest in lockdown exit strategies that preserve lives while protecting livelihoods.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThirdly, we have presented the respondent business opinions on the emergence of COVID-19 and the cultural and religious labeling given to the pandemic. The mains opinions of people in line with the conspiracy and business view of COVID-19 is from one side the epidemic is a business opportunity for country authorities to earn money from international partners and from the other side the fraudulent increases of COVID-19 cases and deaths. This perception has leaded people fearing going to hospital assuming they will be killed to inflate mortality and increased cross contamination in community. Kinga Bierwiaczonek and \u003cem\u003eal\u003c/em\u003e. brought out that conspiracy theories about the origins of COVID-19 have been largely spread and have even been propagated by highly ranked state officials and politicians. Their multivariate growth curve analyses showed that, although conspiracy beliefs decreased and social distancing increased over time.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Moreover, believing in and being confronted with a COVID-19 conspiracy theory decreased institutional trust, support of governmental regulations, adoption of physical distancing, and to some extent social engagement.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlso an example of the cultural and religious labeling is the opinion that the population thinks that COVID \u0026minus;\u0026thinsp;19 is a satanic disease, for example because of the closing of the churches, but the markets were keeped working. Aysegul and Medeiros have demonstrated that cultural attributes do account for some of the global disparities in COVID-19-attributed health outcomes. As a consequence, policymakers should more explicitly consider a society's cultural attributes in order to develop better tailored and more effective policy responses.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e A community based study on prevention of COVID-19 among Religious Clerics and Traditional Healers in Ethiopia found that the majority of the participants had poor practice and negative attitudes. Therefore, there should be a sensitization program to fill the gap.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e Kosarkova and \u003cem\u003eal.\u003c/em\u003e, findings showed associations of spirituality and religious fundamentalism with religious conspiracy theories about COVID-19 vaccination. Furthermore, spirituality was linked to a higher possibility of vaccine refusal.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e A cross sectional study conducted during COVID-19 noted that religion was associated with the frequency of interactions, perceptions of the duration of the social distancing measures, changes in emotional state and history of psychological illness .\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMoreover, it\u0026rsquo;s raised from the stakeholder\u0026rsquo;s opinions, the perspective for self-reliance in the strategies and resources in health risk management. In this regard, the analyze emphasis on the key role of stakeholders from the south in the dialog for change aiming at self-reliance in the health risk communities\u0026rsquo; perceptions, strategies and resources. The mains challenges in the health sector in Africa identified Obinna and al., were inadequate human resources, inadequate budgetary allocation to health and poor leadership and management. The leading solutions proposed included training and capacity building for health workers, increase budgetary allocation to health and advocacy for political support and commitment.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e It cautions that it might not be possible to adequately implement those solution without a concerted fight against corruption, sustained domestic and external investment in social sectors, and enabling macroeconomic and political environment.\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"6 Conclusion","content":"\u003cp\u003eThe dynamics in attitudes observed within the community brings out the challenges of community engagement in the context of COVID-19. The response to COVID-19 has resulted in the need to apply restrictive measures that have required a behavioral change in the population. Therefore, investigating the perceptions and determinants of implementation of restrictive measures is a good approach. However, to ensure these elements bring added value to the implementation of the health risks response, they should be integrated on the basis of a participatory consultation considering the resources available in the management program.\u003c/p\u003e \u003cp\u003eOur bottom-up investigations findings present and discuss entry points for promoting adherence to COVID-19 control measures. Perceptions of COVID-19 as a white man's disease, conspiracy theory and business theory from the community are highlighted. These perceptions arise mainly from the experience of non-transparent management of some previous crises, funded by NGOs and where the community does not perceive their benefits. Nevertheless, cases of increased spread of the COVID-19 and mortality have led to a greater acceptance of the disease risk. Response program authorities should develop two- way communication channels to integrate population expectations, constraints to implementing response measures, information needs. In line with the \u0026ldquo;utilitarism justice\u0026rdquo; and \u0026ldquo;ethics of the health risk response\u0026rdquo;. We argue that when the health response requires control measures that restrict fundamental freedoms, response strategies must move from the Ministry of Health offices to the field where the community considers itself to be an expert in its own situation.\u003c/p\u003e \u003cp\u003eDuring the first wave of COVID-19, informants pointed to self-reliance in views of health program partnerships. The insights from our study consider that Southern actors have the key role to undertake change. And the major driver is the mobilization and efficient allocation of local resources and initiatives. The health institutions seem to prioritize external aid and strategies recommended by international agencies. Community actors have the same posture, they attack actions in partnership with international agencies mainly because they perceive that NGO actors are better treated compared to the income of the state agencies employees. Without the awareness of the community on the impacts of NGOs, they will not be significant adherence to the actions they undertake in the community.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study received ethical clearance from the Ethical Committee of the Official University of Bukavu. All methods were performed in accordance with the relevant guidelines and regulations. Written/oral informed consent was obtained from all the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eClinical trial number\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eC.A.I. has designed the work, interpreted the data and applied per review revisions. P.K.B. has collected the data and interpreted the data. E.E.G., J.B.M., N.F.C. and, M.R.B. have collected the data. B.Z.A and F.B.R. have applied per review revisions. N.A.M. and Y.C. have drafted the work and revisited it. All authors have reviewed and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe acknowledge the scientific support from the team of the following institutions : BEBUC Program, CEGEMI of UCB and IRG-PH of UB.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eWorld Health Organization. Communication du risque pendant les urgences sanitaires Communication du risque pendant les urgences sanitaires. 2018. Available on: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/iris/handle/10665/272269\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRed Cross. 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(2008), 1(27).\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, restrictive measures, health risk, management, self-reliance","lastPublishedDoi":"10.21203/rs.3.rs-6215975/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6215975/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCentral African countries face global health problems caused by emerging diseases that have significant social and economic impacts such as Ebola, COVID-19, HIV/AIDS, Chikungunya, Rift Valley Fever, Avian Influenza, Newcastle Disease, etc. The efficient management of emerging diseases often involves restrictive and constraining responses to fundamental rights, which require long-lasting social and health security schemes. The governments have not yet been able to establish these schemes in Central African countries. In this difficult conjuncture, it is important to question the integration of the situations of poor communities as well as the responsibilities in view of the self-reliance of health management strategies. Particularly, the COVID-19 pandemic has led governments to apply restrictive control measures that have required a sudden behavioral change in the population. For organizational learning, it is necessary to analyze situations of resistance to COVID-19 response measures. Using a socio-anthropological survey this study provides a retrospective community feedback and discusses organizational perspectives from the experience of first wave COVID-19 restrictive measures in Bukavu city, South Kivu, Democratic Republic of the Congo.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative study was conducted between April and July 2020 in Bukavu town, South Kivu, DR Congo. We used a socio-anthropological survey and a literature documentation for discussion. A total of 86 individual semi-structured interviews lasting a maximum of one hour and 5 focus groups discussions were conducted in the three communes (Ibanda, Bagira and Kadutu) of the city of Bukavu. Various stakeholders have participated to the survey such as unformal drug seller, students, shopkeeper, household responsible, state health agencies workers, unemployed youth, clinical healthcare providers, housewives, adult without schooling, a lawyer and clinical healthcare providers in the COVID-19 treatment center. These interviewed actors were selected through convenience sampling. First, they were selected based on their availability and willingness to participate in the study. Also, the informants were targeted according to the information we aimed to collect from them. The theme explored during the individual interview and focus group discussion was the community perception on restrictive COVID-19 measures and behaviors risks; and the factors that represent obstacles to the adoption of the response measure. The interview recordings were translated and transcribed. We used the thematic analysis method to progressively present and discuss the survey results by identifying recurring themes from the data.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe study revealed cases of the community members understanding of the scientific characteristics of COVID-19, their perceptions about the geographical emerging of the COVID-19 pandemic, their business opinions on the emergence of COVID-19 and the cultural and religious labeling of the pandemic. Also, community feedback on restrictive COVID-19 measures is enhanced and explicitly puts forward the expectations and suggestions, constraints to implement these measures. Moreover, it\u0026rsquo;s raised from the stakeholder\u0026rsquo;s opinions, the perspective for self-reliance in the strategies and resources in health risk management. In this regard, the analyze emphasis on the key role of stakeholders from the south in the dialog for change aiming at self-reliance in the health risk communities\u0026rsquo; perceptions, strategies and resources.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe dynamics in attitudes observed within the community brings out the challenges of community engagement in the context of COVID-19. The response to COVID-19 has resulted in the need to apply restrictive measures that have required a behavioral change in the population. Therefore, investigating the perceptions and determinants of implementation of restrictive measures is a good approach. However, to ensure these elements bring added value to the implementation of the health risks response, they should be integrated on the basis of a participatory consultation considering the resources available in the management program.\u003c/p\u003e","manuscriptTitle":"Organisational learning from community feedbacks on COVID-19 restrictive measures and health management self-reliance perspectives: a socio-anthropological case study in Bukavu, DRCongo","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-13 08:21:00","doi":"10.21203/rs.3.rs-6215975/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"45858498046351410280553065216229282774","date":"2025-06-18T13:43:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-16T12:23:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324386499099625054292993151908040924467","date":"2025-06-16T10:48:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67032163753833113112865215190995531606","date":"2025-06-11T11:46:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-11T09:23:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-16T10:18:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-17T13:28:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-17T13:24:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-03-13T03:13:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"19a68b10-8dcd-4bea-a5e6-7c5f7e76f92a","owner":[],"postedDate":"June 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-13T08:21:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-13 08:21:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6215975","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6215975","identity":"rs-6215975","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}