How COVID-19 restrictive measures were not implemented in Bukavu, DR Congo: a participatory qualitative case study 

How COVID-19 restrictive measures were not implemented in Bukavu, DR Congo: a participatory qualitative case study | 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 Case Report How COVID-19 restrictive measures were not implemented in Bukavu, DR Congo: a participatory qualitative case study Christian Ahadi Irenge, Parfait Kaningu Bushenyula, Gaston Masimango Maombi, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6502452/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Health systems in study setting were inadequately prepared for the COVID-19. Our research aimed to contribute to describe, through a socio-anthropological study, the different dynamics in the non-compliance to COVID-19 response measures, in Bukavu city, Democratic Republic of the Congo. We argue that, continuous application of the COVID-19 restrictive measures required relevant resources and competencies in a transparent management of the response pillars such as risk communication, epidemiological surveillance, prevention and control, laboratory organization, medical and psycho-social care and logistics. Methods: A qualitative study with a socio-anthropological survey was conducted in Bukavu Town, South Kivu Province, in Democratic Republic of the Congo. An exploratory survey aiming at co-producing the study objectives with key stakeholders was conducted with 17 participants including academics, health professionals including technical agents of the COVID-19 response and community members. In- depth 86 semi-structured interviews and 5 FG each of 7 to 11 actors were organized. The interviewed actors were selected through convenience sampling and the saturation of data indicated the it size. 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. We have triangulated the opinions collected in order to verify their veracity. 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 in the data sources. Results: The study present a timeline of dynamics in the non-compliance to first wave COVID-19 measures in Bukavu, Democratic Republic of Congo. The analysis begins with the echo of the emergence of COVID-19 internationally on social media and it influence on the population's understanding. Following by, the sporadic compliance with the response measures from the experience of the first cases of COVID-19. Next, the determinants of the COVID-19 alert full down and the breakdown in the application of preventive measures are presented. These determinants are argued around (i) the inadequacies in coordination illustrated with the case of resignation of Noble Prize winner Mr. Dr. Mukwege from the COVID-19 response committee. (ii) Then, the community socio-financial disability as barrier to response adoption. (iii) Following, the lake in public order services to monitor the completion of response measures. (iv) And the gaps in the health system structure and the negative legacies of the management of the previous Ebola epidemics waves in DR Congo. Conclusion Establishing strategies to respond to emerging diseases is a complex challenge in fragile system contexts with inadequate health security schemes, surveillance and preparedness. As to achieve community engagement in such context, the COVID-19 response explored should benefit from an integrated complementary strategies such as the accompaniment of the most disadvantaged people, concetualized sensitization, and the application of incentives to motive the compliance. health outbreak COVID-19 restrictive measures risk communication incentives compliance 1 Introduction Restrictive measures are an important intervention in public health. In the SARS outbreak of 2003 and the Covid-19 pandemic, mass quarantine was employed ( 1 ). The emergence of extensively drug-resistant tuberculosis (XDR-TB) has also raised the issue of the use of isolative measures ( 2 ). Justifications for public health action involving restrictive measures have been grounded in different considerations on different occasions; that is, depending on the nature of the contagion and measures in play ( 3 ). Upshur have designed a public health ethics framework that identifies 4 principles—the harm principle, proportionality, reciprocity, and least restrictive measures—to guide public health intervention ( 4 ). Programs that are coercive should be implemented only in the face of clear public health need and good data demonstrating effectiveness. For public health to restrict liberties, observes Callahan, it must provide solidly based factual evidence, in other words, provide objective, scientific, hard facts to validate decisions that override autonomous decision making ( 5 ). Restrictive measures as enables individuals to voluntarily comply requires to be proportional to the threat and implemented along with reciprocal arrangements provided to those affected. Also to be accompanied by open and transparent communication throughout all stages so that citizens can both understand and participate in decision-making ( 6 ). On an instrumentalist view of motivation, individuals will be motivated to support and comply with public health measures if there is some direct benefit associated with compliance or sanction for non-compliance with the measures. On a normative view of motivation, individuals will be motivated to support and comply with public health measures if they regard such measures as morally appropriate, as opposed to contributing simply to their self-interest. ( 3 ). While consequences such as fines and community service were found to be important for those who do not comply with restrictive measures ( 6 ). According to the World Health Organization, 2020, RECC 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. 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. It is therefore recommended that systems be put in place to detect and respond to expectations, rumors and misinformation ( 7 ). The goal of risk communication and community engagement (RCCE) is to promote informed choices, foster positive behavioral shifts and uphold trust. It is a vital component of pandemic prevention, preparedness and response. RCCE should aligning communication approaches with community values, norms and cultural context messages can be more persuasive and impactful in promoting desired behaviors ( 8 ). A review have report that key barriers to effective health communication included misinformation, distrust, limited collaboration, and messaging inconsistency. Major gaps were identified in mass and social media strategies, characteristics of messages, sociocultural contexts, digital communication, rapid response, providers’ attitude and perception, and information source characteristics ( 9 ). Porat et al., propose practical guidelines for public health and risk communication as following: (i) create an autonomy-supportive health care climate; (ii) provide choice; (iii) apply a bottom-up approach to communication; (iv) create solidarity; (v) be transparent and acknowledge uncertainty ( 10 ). A study on risk communication on behavioral responses during COVID-19 in China highlight the fact that the population exposed to risk communication messages were positively associated with engaging in preventive behaviors. Whereas, believing in misinformation were negatively associated with wearing masks when in public. An inadequate supplies of personal protection materials were negatively associated with their outdoor hygiene behaviors ( 11 ). The study have been carried in South Kivu is one of the poor provinces of DR Congo with almost six out of seven inhabitants live below the poverty line ( 12 ). This region has a considerably high morbidity and mortality rate of infectious diseases such as malaria, cholera, tuberculosis, measles, bubonic plague, yellow fever, Ebola Virus Diseases, etc. ( 13 ). at the same time, the rate of non-communicable diseases is on the rise. In this region, the health system has shortcomings (infrastructure, equipment, human and financial resources, etc.) and the rate of access to health care is low. This health system has faced challenges in coping with the COVID-19 pandemic. The DR Congo has developed a strategic plan against the COVID-19 epidemic in line with the control strategies proposed by the WHO ( 14 ). There is gab in the evidences that describe about the failure of restrictive measures against covid-19 in fragile systems that have experienced decades of epidemics. This study aim is to analyze the dynamics adherence to COVID-19 restrictive measures in Bukavu town, South Kivu province, in DR Congo. For organizational learning, it is necessary to describe the cases of resistance and non-compliance with COVID-19 restrictive measures. 2 Objectives This case study aims to describe, through a participatory socio-anthropological survey, how COVID-19 restrictive measures were not adopted in Bukavu town, in South-Kivu province, in Democratic Republic of 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. It is a region where living conditions is impacted by decades of armed conflict, political and economic instability. The emergence of COVID-19 in this same context, as well as the application of COVID-19's restrictive contingency measures have resulted into 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 COVID-19 restrictive measures. 3.2 Design of the study Data collection and participatory approach For this case study, we have used a socio-anthropological survey to collect data ( 15 ) and inductive analysis to present the qualitative data ( 16 ). Survey was conducted in the 3 communes of the city of Bukavu town between April and July 2020. An interview guide was established with open-ended questions. On the filed the participatory approach we applied consisted in conduct exploratory surveys was conducted with 17 participants including academics, health professionals including technical agents of the COVID-19 response and community members. The objective was to involve these stakeholders in the study design ( 17 ). 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 with 86 participants by organizing semi-structured interviews. The interviewed actors were selected through convenience sampling and the saturation of data indicated the sample size ( 18 ). 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. Additionally, the snowball approach consisted in respondents telling us which of their colleagues they felt would be best-placed to be included in the survey. In order to verify the information and to be able to produce agreed opinions, we were triangulating the opinions collected by the different actors ( 19 ). Data processing and analysis The interview recordings were translated and transcribed. We used the thematic analysis method ( 20 ) to progressively present and discuss the survey results by identifying recurring themes in the data sources. 3.3 Ethical considerations Because this study involves humans, ethical considerations require that they give their free and informed oral consent. Participant were consulted for their permission to record the interviews. During field data collection; local traditions, folk customs, norms and values have been respected. In addition, the ethical principles of respect for persons, respect for the interests of justice of respondents, and respect for communities have been observed. 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 multisector plan against the epidemic to ensure an effective response. At the community engagement level, which is one of the key 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 ( 14 ). 4.2. Information about the study participants and theme explored Table 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 the questions formulated prior to data collection. 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 Positiveand negative aspects of COVID-19 response -COVID 19 response measure problems -Contrast of compliance -Existence Recognitions -Treatment and prevention impact -Mask wearing -Hand sanitizer use -Confinement -Lock down -Travel restrictions 4.3. Social media relays of the COVID-19 spread abroad and its influence on the people perceptions In the period following the declaration of the emergence of the pandemic in December 2020 in China, when the DRC had not yet recorded any cases of COVID-19, social media spread an alert about the high contagiousness and the implementation of contingency plans in several countries. The population of Bukavu City percieved these alerts on the emergence of COVID-19 into their own understanding beyond the scientific reality. This situation had influenced the community commitement to the response. During the survey, the following understandings were noted within the community. The table 3 present interviewer’s perceptions on the COVID-19 origins and existence. First, a perception among actors that the DR Congo system will find it difficult to respond to the COVID-19 epidemic compared to the difficulties encountered in the management of COVID-19 in the developed countries. This is because health system of Northern countries, perceived as efficient model of management, were already experiencing high morbidity and mortality. Also, the stigmatising information on the pandemic conveyed en masse by social media has been translated into religious beliefs as a bad divine omen to which the population has envisaged solutions of a spiritual nature. A religious believer, a pharmacy assistant, interviewed in her pharmacy said that: “People die from breathing the "corona" in the air in Europe, so here in our country it will be more devastating... It seems that it is a sign of the end of the world, we must pray for God to preserve us from it and be ready for the coming of the Lord" (excerpt from an interview with a pharmacy assistant-in a dispensary, Bukavu/DRC, July, 2020) Africa has 15.3% of the world's registered Muslims, and 23.6% of the total Christians, both of them are increasing steadily ( 21 ). Asare, 2017, present in a narrative discussion that in Africa, there is spiritual involvement in the treatment of disease and health care. According to this author, the new model of health in African cultures can therefore be considered as biopsychosocial model. The case study on dissociative amnesia illustrates that Africans consider spiritual causes of illness when the diagnosis of an illness is very complex. The spiritual beliefs of African patients should not be dismissed but should be used by health care providers to guide and facilitate clients' recovery from illness. The alert of the emergence of COVID-19 and the application of restrictive measures such as confinement of the population have raised concerns about the resources of vulnerable populations. An actor from the informal sector, a shoe repairer, expressed his fear in this sense: "...it seems that the corona is already in Kinshasa and that we are going to be confined as well, those who have the means are getting food, the rest of us are going to die of hunger" ( extract from an interview with a shoe repairer, Bukavu/DRC, July, 2020) It is a fact that the interactions between socio-cultural influences and the flow of information primarily about the high risk of mortality from COVID-19 has led to an awareness of the existence of the pandemic. But all this without an adequate understanding of the pathogenicity and the importance of measures of prevention. 4.4. Sporadic compliance with the response measures from the the experience of the first cases of COVID-19 Like a new lifestyle, the massive wearing of masks has marked the streets of the city of Bukavu in the following of the communication of the response measures to COVID-19 by the city authorities. From the above, the media coverage of the risk related to COVID-19 (this risk expressed in the media in terms of "high morbidity and mortality in the better organized systems of the developed countries, etc.") has raised awareness of the risk. ) have raised awareness of the fact that the COVID-19 pandemic exists. Apart from the fact that this leads to concerns about the survival resources of the vulnerable in case of application of the very restrictive measures and to spiritual interpretations based on religious beliefs. Also, the approach to communicating the health risks associated with the first cases of COVID-19 in South Kivu has influenced the adherence to the response measures at a given time. Indeed, the first case of COVID-19 was reported in DR Congo (in the capital city of Kinshasa) on March 10, 2020. Fourteen days later, a "state of health emergency" was declared by the Presidency of the country. With regard to acceptability to the population, the response plan included strengthening risk communication and community engagement through the strategies mentioned in the previous section. A series of other preventive measures followed, the most restrictive of which was the lockdown. On March 30, 2019, the first two positive cases were declared in the city of Bukavu by the Governor of South Kivu Province. Initially, the established risk communication strategy had a positive influence on the adoption of preventive measures. For case in point, the provincial governor, Theo Ngwabidje had stated in a communication: "I would like to inform the population of our province on the threat of COVID-19, which is in the national and global news. Indeed, since yesterday 19 March 2020, the province of South Kivu has recorded two cases tested positive for the Coronavirus in Bukavu. Thanks to the vigilance and professionalism of our technical services, the two cases have already been put in isolation, and were, under my personal supervision, during the night, transported to the treatment facilities set up for this purpose ” (Journal Actualité. Cd, 30 mars 2020). He further invited the population of South Kivu to remain calm, and to observe hygienic measures in order to limit the spread of the disease: "I ask the population to remain vigilant, that they do not panic, because a virus as dangerous as the coronavirus, can not be defeated by fear but rather by the implementation of hygiene measures, and the collaboration of all of us: health professionals, journalist, social communicators, local, national and international NGOs ... The province has already taken protective measures that are being strengthened to protect our population that risks contamination on a large scale, "he added é (Journal Actualité. Cd, 30 mars 2020). Indeed, following the first outreach on the first two cases of COVID-19 in Bukavu, prevention practices were sometimes observed. The community awareness that was set up mainly through audio-visual media, awareness campaigns had as key messages: the risk of mortality, social distancing, reporting of suspected cases via a call center, wearing masks, use of disinfectants and suspension of activities likely to cause gatherings (schools, religious cults, weddings, mourning, festivities, sports activities, bar, discotheques, etc.). The Table 4 present main reactions and attitudes of people to some COVID-19 barriers measures. Table 4 Reaction to some COVID-19 barriers measures Theme explored Main opinion from Data Exemples of citations Sanitary containment - Good measure if it could be respected, - Impossible given the low socio-economic average - Good measure if the state helped people to survive - Useless because not respected "...containment is a formality in Bukavu because it has not been respected, let's uncontain the city and let people learn to live with this virus while respecting the response measures since we are going to die with hunger..." Phamacy holder, Bukavu/RDC, July 2020. « That measure of staying at home that might not be possible because of the problems. For example, I spend all day here trying to find a measure of flour to eat every day, but I don't know how I can stay at home when there's no help. » Responder Without school education, Bukavu/RDC, July 2020. "Let's say in a family where both parents are teachers they haven't received anything for over 3 months but you tell them to STAY HOME, to do what then. I don't see how" Student, Bukavu/RDC, July 2020 Nose Mask - Good if understood by the public - Doubts about effectiveness - Difficult for some « …the measures would be good but they are not respected, there are those who put their masks on the neck instead of the nose and others don't have any. » Head of household. Bukavu/RDC, July 2020 « …also I think they did a good job of giving people information about the measures, for example with the nose masks I find a lot of people respect that either for fear of being arrested » Respondant without school education, Bukavu/RDC, July 2020 « …when we know that the Covid-19's existence is false, why wear a nose mask ? » Student, Bukavu/RDC, July 2020. « There are also others who can't afford it, so it would be better to help them. » Student, Bukavu/RDC, July 2020. Social distanciation - Good measure but difficult to apply in our context « …people spend all day at the market being crammed in, yet at church it's less than 3 hours. » Phamacy holder, Bukavu/RDC, July 2020. « Social distancing, first of all, is something I can't say is normal, because you can't tell a person to walk one metre closer, you start walking with a tape measure or whatever, it can't really be done » Student, Bukavu/RDC, July 2020. « Social distancing is difficult, at least for us in the DRC. » Student, Bukavu/RDC, July 2020. Closing churches and schools : - Good measure - A good measure, but it's already been many months - Unnecessary because markets are always open all day while church doesn't take up as much time « About schools and churches, I didn't understand how the churches could be closed when you just go in for 1 or 2 hours and then leave, whereas the market is open all day and hasn't been closed. That's when I had a bad thought too, if only the church had problems. We shouldn't have closed it, we shouldn't have closed it because it looks like we're leaving. Why was the all-day market spared? » Respondant without school education, Bukavu/RDC, July 2020 « As far as schools and churches are concerned, I don't think we can go on like this. Let's find out who's really going to allow us to start classes and open churches! » Student, Bukavu/RDC, July 2020 « First of all, we'll have to ignore this solidarity and Christianity, and respect the barrier measures first. These are the measures that will enable us to get back to normal activities without any problems. » COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020. Hand washing -Good mesasure -Good to prevent other diseaseas a part from COVID-19 « Concerning hand washing is concerned, many people have respected this because you will see people washing their hands before entering health centers; schools, in markets, many have washed… » Respondant without school education, Bukavu/RDC, July 2020 « …there are those who still resist, but others who have understood and are beginning to respect the measures to combat this disease. » Public Health Professional, Bukavu/DRCongo, july 2020. « …up to now, there are those who neglect the barrier measures and they don't mind because they think it's a "cop" or a deal » Jobless Youth, Bukavu/DRCongo, Jully 2023 As a result of the communication efforts, many of the study participants described having adequate knowledge and prevention practices: "There are those who say that the emergence of COVID-19 is an arrangement of a deal by the government that wants to benefit from the financing of the response, but personally I believe that the disease is here, it is spreading worldwide. I mobilize my family to wear face masks and everyone should do the same" (Father of the family, Bukavu-DRC, April 2020) "Covid19 is a contagious disease that is transmitted through contact, if we don't apply the barrier measures and the lack of adoption it is a reality in Bukavu" (from an interview with a Drug Vendor in an informal public pharmacy, Bukavu/DRC, April 2020). In particular, we noted that the experience of the announcement of a confirmed case of COVID-19 in a resident of the Bagira area, in the city of Bukavu, motivated many residents of this area to respect the measures of containment and social distancing as well as the wearing of masks in public places and on public transport. An informant living on the same street as the person who tested positive for COVID-19 told us the following experience: "...when our neighbor tested positive for COVID-19, you had to experience the panic and fear of being contaminated, we didn't leave the house for days, we didn't greet each other with our hands, everyone wore masks in Bagira, we respected the distance in the bus.... ". (Student in pharmaceutical science, Bukavu-DRC, July 2021). The same source told us that: "... and as the family of the alleged patient felt insecure, they denied it on social networks saying that the person of the family who was returning from a trip from Europe did not have the corona...and progressively with many rumours the tension ceased in Bagira" (Student in pharmaceutical science, Bukavu-DRC, July 2021). In addition, with the suspension of incentives, there has been a decrease in the application of preventive measures. We have analyzed in the following part of the article the components of the situation breakdown. 4.5 Breakdown in the application of COVID-19 barrier measures: coordination of the response, communication activities, establishment of incentives, the socio-financial imbalance and t the Health System structure gaps However, the situation of vulnerability of the population in South Kivu as introduced above, the risk communication implemented and the shock of awareness linked to the incidence of the first cases of COIVD-19 led to a temporal understanding of the risk and the application of preventive measures by the population. Nevertheless, our analyses show that the continuous application of the measures would require complementary strategies such as the accompaniment of the most disadvantaged people, continuous sensitization, the application of incentives to respect the response measures (through the control of public order services, etc.). Also, the transparent coordination of the pillars of the COVID-19 response program such as epidemiological surveillance, prevention and control, laboratory organization, medical and psycho-social care and logistics. These pillars of the COVID-19 response are included in the policies for the fight against COVID-19 in the DR Congo ( 14 ) as well as in the global strategy for the fight against COVID-19 whose main goal is that all countries control the pandemic by slowing down transmission and reducing mortality associated with COVID-19 ( 22 ). Based on consultations with key stakeholders in the Bukavu COVID-19 response system, we present shortcomings in the response actions that would have led to the lax application of barrier measures. The Table 5 summarize the respondent’s reactions about the COVID-19 barriers measures. Table 5 Perception of COViD-19 origins and existance Theme explored in the survey Main opinion from Data Exemples of citations Perceived origin of COVID-19 - From China - In the white world - Annecdotes: Demons, government and/or healthcare staff business, illusion, "COP" or "DILI" to say a business to make money, a way to enrich themselves for some. « …there are those who say it's a government deal to enrich themselves by funding the response, but personally I don't think that's the case - the disease is real! » Household head, Bukavu/RDC, July 2020. « …it's one more suffering in our lives and it's coming from the West among the Whites (bulaya) since we didn't know such a misfortune was going to happen to us, children don't study anymore, and those who have studied have no jobs, famine… » A display retailer Women, Bukavu/RDC, July 2020 « …as Ebola has made people rich, some have thought that this disease will also enrich those responsible for the response. ». A display retailer Women, Bukavu/RDC, July 2020 « …COVID-19 is a pandemic that is making the newspapers and affecting all sectors of life. It is said to come from the pangolin in china, but we can't be sure of anything since we have several pieces of information in our possession as to its origin ». Unemployed youth, Bukavu/RDC, Jully 2020. "...It has to be recognized that this is a disease that existed in certain regions of the world, notably in Asia, Africa and the Mediterranean regions of Africa, such as Algeria, Egypt and Tunisia, and now we have the second form of coronavirus that has reached all regions of the world." COVID-19 treatment center care personnel, Bukavu/RDC, Jully 2020. Perceived existence of COVID-19 Some think it exists, others doubt it. « …but I'm thinking that it hasn't arrived here yet, but it's the people who want to make it more severe. » A responder without school education,, Bukavu/RDC, July 2020 « …we can only believe in his presence here, given the closed schools and churches… » Student, Bukavu/RDC, July 2020 « ...Initially, people did not believe in the disease and thought it was a lie or a way for the authorities to get rich, but with the few people who died, the population began to understand... » Public Health Professional, Bukavu/RDC, July 2020 4.5.1 Inadequacies in management: case of the effect of the resignation of Noble Prize winner Dr Mukwege from the COVID_19 response committee in South Kivu Some weaknesses in coordination have been unfavorable to community engagement in the response. One illustrative situation is the resignation of Nobel Prize winner Dr Mukwege. Indeed, appointed on 30 March as director of the response commission against the coronavirus by the governor of South Kivu Théo Kasi, Dr. Denis Mukwege submitted his resignation on June 2020, stating that the decision to resign was "in order to devote myself entirely to my medical responsibilities and to treat this influx of patients at Panzi Hospital" ( 23 ). In South Kivu, the resignation of Dr. Mukwege (who is presented as an actor trusted by people) has raised suspicions of mismanagement of the response. Congolese political class, public opinion and social networks talked about affairs in the crisis by public actors. This opinion became widespread and maintained that the Covid-19 crisis is no longue a threat but an occasion for the gathering financial resources from international aid. In addition to this, there were various contradictions in the communication of the Covid-19 cases at various levels of management. In this regard, provincial governors were sometimes contradicted by the national response team. This has led to doubts about the veracity of the incidence of the disease in the community. For example, on 3 April 2020, the national authorities published an epidemiological bulletin announcing a third new case in South Kivu. This statement was contradicted on 06 April by the provincial authorities, who stated that it was one of two old cases tested twice by mistake ( 24 ). As presented in the Table 6 , some informants emphasized the poor management of the response to COVID-19. A resident of the Ibanda commune said: Table 6 Feedback to COVID-19 response management Theme explored Main opinion from Data Exemples of citations Response activities Treatment: - Good because the cured are talked about - Doubts about the effectiveness of this treatment - Bad, since some hospitals charge for treatment of this disease - Bad, since the response manager had resigned Communication : - Ineffective due to lack of trust - Ineffective in raising public awareness and understanding - Predominance of rumors and publicity for other organizations or hospitals - Contradiction and instability in communication activities « When the coronavirus disease was declared in Kinshasa, it was said that there was a handover between Ebola and Covid-19 » Respondent without school education, BuKavu/DRC, Jully 2023. "...in my opinion the management is not good since seeing first of all the person in charge of the riposte the Noble Prize Dr Denis Mukwege resign." Phamacy holder, Bukavu/RDC, July 2020. « Health professionals are raising awareness throughout the city, but some people are not making their task any easier by refusing to comply with barrier measures… » » Public Health Professional, Bukavu/DRCongo, july 2020. "...the response is effective and the government has made available hand washes, hydroalcoholic solutions, soaps, etc. If people respect these measures, we have a chance of getting through this well." Public Health Professional, Bukavu/DRCongo, july 2020. « In Bukavu they said there were 3 cases, then they said it was cured, but when they found out that there were funds coming from America, they announced again that there were three cases that hadn't been cured. So as far as I'm concerned, there's no covid19 in Bukavu ». Student, Bukavu/DRCongo, july 2020. « And the population, left sadly in its corner, thinks it's all about Covid-19 cases and politicians making money, while hospitals take advantage of the situation to kill people in order to earn money for the survival of their care units. As a result, people will be afraid to come to the hospital for treatment. » COVID-19 treatement center care woker, Bukavu/DRCongo, july 2020. « The street demonstrations in Bukavu are very alarming, because I saw people protesting at the covid19 treatment center in Bukavu, breaking the windows and saying they wanted to free the patients who were there. » COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020. « ...Also, concerning the communication on the number of cases, the provincial secretariat of the response team gives a number while the lab in Bukavu gives a different number. » COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020. « About management I'm going to assume that our province was on the right track with only one covid management center but unfortunately I don't know if it's greed or not, they decided to keep COVID positive people in hospitals and so there were outbreaks so that 40 percent of the nursing staff were affected. » COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020. Encourage people to follow response measures - Communicate the importance of these measures - Set an example - Make it mandatory and impose fines and arrests on those who fail to comply with these measures. « I have to set an example for them, starting with my children and my husband, but also show them that the consequences of neglecting these measures are bad ». Display retailer Women, Bukavu/RDC, July 2020 « …is by preaching by example, washing our hands and above all respecting social distancing… » Public Health Professional, Bukavu/DRCongo, july 2020. « …if there was help like there was in other countries, we too could stay indoors. Because we learned that in other places (countries) like Tanzania they gave them 60 kg of rice, flour, beans as well as sugar and salt... » Respondant without school education, Bukavu/DRCongo, july 2020 "What I'm proposing is that they collaborate with the public because they may have ideas, but the public may also have ideas that would enable us to live with covid19." Student, Bukavu/DRCongo, july 2020. « Force won't do any good because people will change the way they bypass them. I think the best way to do this is just to work on people's awareness. » Health care professionnal, Bukavu/DRCongo, july 2020. "Providing food to some of the poor ( poor people) will alleviate the most sensitive economic problems." Health Professional, Bukavu/DRCongo, july 2020. « First of all, I don't think it should be obligatory, but rather that people should be made aware of the dangers of COVID 19. » Lawer, Bukavu/DRCongo, july 2020. Improving response management - Keep up the pace of awareness-raising - Collaborate with the population - Help people with hand-washing devices and nose masks - Integrate people who are qualified and competent into the response team - Put their oath as healthcare workers before anything else set up a covid19 testing laboratory in each commune of Bukavu « …ask the provincial authorities and their team to involve intellectuals in the response, because many of those we meet in the field have not studied… » Household head, Bukavu/RDC, July 2020. « …to be close to the community living with this virus, it's really important that the community finds a space to express itself and that their cries are taken into consideration. » Unemployed youth, Bukavu/RDC, July 2020. « We don't trust them, we don't trust our governors, which is why it would be really difficult to apply everything they tell us, despite what they've done, with TV and radio campaigns. » Student, Bukavu/RDC, July 2020. « They've already revealed everything, and we know that they're after money, and that's very clearly visible. I don't think we can trust them anymore, despite what we may say ». Student, Bukavu/RDC, July 2020. Concerning barrier measures, I think there's also a problem of awareness. Even nursing staff find it hard to wear a nose mask all day long, so how do you expect non-healthcare staff to manage without having properly explained the benefits of this mask to them? COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020. « We really need to rethink our communication methods, the types of ads to run on the radio and the types of messages to be conveyed. We need to know what message to get across, and who can get that message to people. » COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020. « The clarity in their publication and the precision with supporting evidence because we are not an illiterate population. » Health Professional. Bukavu/DRCongo, july 2020. "The management would seem to be working well but after considering Denis Mukwege's resignation first of all. The reasons for his resignation are his own, but we believe that it is because he did not get along with his colleagues due to the fact that there was funding managed inappropriately…. All these measures are not important because there is no COVID, I don't really agree, these measures are to distract people" (extract from an interview with an inhabitant of the commune of Ibanda, Bukavu/DRC, July 2020). On the other hand, concerning the management of COVID-19 in the city of Bukavu, while the population stayed suspicious of the presence of COVID-19 and the application of prevention measures. This annoyed public authorities who were too confused by the epidemiological context. Of the most important, the provincial governor, Théo Ngwabidje, expressed his anger in passing: "Bukavu, shiye bote tuko bayuwayi", he said in Swahili, all indignant. Translation: "Everyone thinks he is an expert in Bukavu". On social networks, the famous sentence of the provincial governor caused a buzz and was used by several internauts to criticise his various decisions in the management of COVID-19. From this, it was clear that the activities of the implementation of the response had contributed to confusion in people's understanding of COVID-19. At the outbreak of the epidemic, those who were on alert and in doubt had raised their awareness by respecting certain barrier measures (hand washing, wearing of masks, use of hydro-alcoholic gels, etc.). Subsequently, they stopped making the effort due in part to a loss of trust in the public authorities and the health system (Table 6 ). One Health care worker said: "...if there is no appropriate and honest communication there is no trust. Even worse if there is bad communication or lies there is destruction and unfortunately this is our context. Yes, we are confuse" (extract from an interview with a health care worker, Bukavu-DRC, July 2020). 4.5.2 Socio-financial barriers as a counter-motivation to implementation of COVID-19 measures When covid-19 occurred, the DRC was going through a period where the new government invested in January 2019 was in the process of setting up new projects to stabilise the political, economic and security situation. It was in this context that the country hosted COVID-19, thus disrupting all sectors of the country. The socio-financial situation of the population of Bukavu was an obstacle to the actions against COVID-19. In this region, the population lives in survival terms beyond the psycho-social trauma caused by the decades of armed conflict in this region, which has led to the collapse of the population's income. In this context, where the majority of the population lives off the land in the informal sector, response measures such as social distancing, confinement, the state of emergency, border closures, urban-rural isolation, etc. have paralysed their activities. The introduction of these measures had been inspired by foreign experiences where the context allowed the population to adopt them. This was in contrast to the context of the DR Congo where these measures should be rethought with regard to the direct (mortality and morbidity) and indirect (loss of resources, etc.) pathological burden of COVID-19. This is why it was not easy for the population to appropriate and adopt these measures, which for them disrupted their daily lives. COVID-19 is indeed a issue that has arisen in the context of other more preoccupying health and economic problems. One of the the opinions of community actors highlight in the Table 7 were as follows: Table 7 Opinions on COVID-19 socio-economic impacts and community resilient attitudes Theme explored in the survey Main opinion from Data Exemples of citations Socio-economic impacts In general, covid is perceived to have a negative impact on the social, economy, éducation, etc. « "...it comes from China and its impact on my life is more than great, it has made us vulnerable."» Phamacy holder, Bukavu/RDC, July 2020. « …our children who stay at home become thieves and on the economic front the dollar rate rises a lot. » Head of household. Bukavu/RDC, July 2020. « I haven't had a job for 3 years since I finished my studies, and the impact of this disease on my life is very great, since even my parents, who still do everything for me, no longer work as they should » Unemployed youth, Bukavu/RDC, Jully 2020. « I see that the Covid is paralyzing everything, even those who work, even shopkeepers no longer sell well » A responder without school education,, Bukavu/RDC, July 2020. "Some activities have decreased and income while other items have increased in price due to the scarcity of products; foodstuffs have increased in price due to the high exchange rate. » Health professional,, Bukavu/RDC, July 2020. Resilient attitude - Sporadic comply with COVID-19 barrier measures - We learned that there are plants that heal : lemon, ecalyptus, avocado leaf, banana leaf, ginger, tetraderma riparia, etc. - MUVUKE": a process that consists of heating water containing certain plants, then covering oneself with a thick cloth containing this still-boiling water and inhaling the steam and feeling the heat for as long as possible. - BIBLE HAIR": the process of leafing through the Bible in search of a hair, then placing it in a quantity of water to be drunk morning, noon and night. - Making masks from pagne fabric - Local production of hydroalcoholic gels « But also to show people that it's not enough to just use soap to wash their hands: the cinders can also work… » Display retailer Women, Bukavu/RDC, July 2020. « …it's not a disease that's well known traditionally it takes years to think about traditional treatment ». Unemployed youth, Bukavu/RDC, Jully 2020. « …the barrier measures in South Kivu are international, so they're effective, and if we're still alive now it's thanks to these measures, which really should be respected if we all want to survive » Jobless Youth, Bukavu/DRCongo, Jully 2023 « …population may also have ideas that would enable us to live with covid19. AIDS exists and we live with it; we've lived with Ebola and influenza, which are also viral diseases. » Student,, Bukavu/DRCongo, Jully 2023 « …The problem is the solidarity we think we have in our country, we think that to be in solidarity with someone is to be tight to them. But no, we can show solidarity by respecting these measures. » » COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020. « At the beginning, people used to talk about "BIBLE HAIR": they would look for hair in the Bible and mix it with water, then drink that water to avoid covid. "It is one more pain in our life and it comes from the West among the whites because we did not know that such a disaster was going to happen to us, the children do drop out of school, and those who have studied are not employed, famine is also here" (extract from an interview with a mother, street vendor, Bukavu, DR Congo, July 2020) "Let's say in a family where both parents are teachers they haven't received anything for more than 3 months? then you tell them to stay at home. So why do they do with STAY AT HOME?," (excerpt from an interview with a student, Bukavu/DRC, July 2020) " I'm not employed already since I finished my studies 3 years ago. the impact of this disease on my life is very significant because my parents who are still doing everything for me are also no longer working as they used to" (excerpt from an interview with an unemployed girl, Bukavu/RD Congo, July 2020). Over time, while the countryside was isolated from the city of Bukavu, the international borders were closed, river transport was stopped, and Bukavu was almost dried out of food. The precarity and growing vulnerability of the population was intensified. These isolated areas were the main suppliers of the city of Bukavu on which many households depend for survival. On the one hand, many people outside the city hold jobs in the city where they are forced to move every day. On the other hand, many of these people provide food in town from which supply and demand are regular (frequent). A health worker said: " ... Let us also note the economic impact of COVID-19 with the fact that we live at the rate of the day, there is no traffic but rather the closure of certain businesses" (extract from an interview with a health worker, Bukavu/DRC, July 2020). Faced with this situation, the population adopted strategies to survive. As a Latin proverb says: "a hungry man has no ears"; this was the case in the town of Bukavu where the coordination of the response had experienced several organisational and technical problems. It was also confronted by the context of food insecurity and the vulnerable nature of the majority of the population. Thus, the response measures suffered in several ways, including the following: ( 1 ) This new pandemic revealed to the population that it had the capacity to use the available resources to fight the disease. It is in this context that the population had put in place mechanisms and practices for a common fight. These include the practice of Muvuke and the regular consumption of lemon juice. This practice had become widespread in the majority of families in Bukavu until the scarcity and increase in the price of lemon on the market was observed. However, other people remained aloof to these practices with little certainty about their effectiveness. A medicine seller said: "So far I have not seen anyone with corona but I see people taking Muvuke only" (from an interview with a medicine seller, Bukavu/DRC, July 2020). A student continues: "I can say that traditionally you can't treat COVID-19. It's just that nowadays a lot of things are going around. First with the Muvuke system, but for me it is a distraction because this mixture made of lemon, ginger, black pepper and drunk after heating is effective in the said disease. The problem remains on the proof of the mode of action of this portion" (extract from an interview with a student, Bukavu/DRC, July 2020). ( 2 ) Most pe ople reported having relied on practices aimed at bypassing the financial problems associated with food supplies. As a result, commercial practices had been disrupted. In terms of rural-urban trade, small traders were opposed to staying at home while the provincial government's decision was already in effect. The decision had been adopted at a provincial council of ministers meeting held on April 1 2020 by the governor, Théo Ngwabidje. The decision was taken on three levels: the closing of all ports, airports and aerodromes in South Kivu for the transport of people, with the exception of cargo; the closing of all roads leading to the territories, with the exception of vehicles transporting foodstuffs and other basic necessities; and the ban on navigation on the lake for the transport of people. The local population took steps to continue their activities under the usual conditions, and to escape the government's decision. As for small cross-border traders, they had initially decided to source their supplies in rural areas, but the poor state of the road was a major obstacle. As a result, some sellers have set up a groupage system to obtain supplies in Cuangugu, a town in Rwanda bordering the city of Bukavu. ( 3 ) Moreover, faced with the lack and high cost of protection kits (masks, hydroalcoholic gel, etc.), local populations developed new practices. All sewing workshops began to make reusable masks for the public and health-care workers, even though these masks were initially considered ineffective by the WHO (WHO, 2020). Other people, including pharmacists, manufactured gels in informal structures; and hand-washing devices were developed by agists. A resident of Bukavu said: "[...] and we mustn't wait for the mask to come to us from the whites, we ourselves have to sew them with cloth" (extract from an interview with a Bukavu resident, Bukavu/DRC, July 2020). In the context explained above, in Africa and in Bukavu in particular, maintaining containment had become an arduous task. All the measures that had been adopted had led to many people losing their jobs and becoming unable to survive. And that's why people were resistant to containment and other measures. People's opinions were divided in an African perspective marked by a spirit of solidarity. Benjamin Djoudalbaye, Head of the Health Diplomatic Policy and Communications Division at the African Union's Centre for Disease Control (CDC), explained: "We shouldn't apply other people's solutions to our problems. I think we are intelligent enough to find solutions adapted to our African context. Containment should be accompanied by a certain number of measures to mitigate the effects, both on populations and businesses". This is how the measures put in place to limit the spread of the coronavirus, as recommended by the WHO, have made people's way of life more difficult. 4.5.3 Need for ongoing communication and integration of evidence of COVID-19 experience The risk communication initiatives put in place have not helped to maintain compliance with barrier measures. First of all, the key messages of health risk communication lack several elements that the public has expressed to us in the form of information needs. In addition, the community's opinion gave more importance to subjects missing from the communication, such as curative treatments, the recurrence of the disease, the pathology's particularities in relation to races, and the expected maximum duration of the crisis. This points to the need for risk management to take account of community feedback gathered through surveys. On the other hand, the communication channels used were not adapted to the local context. In addition to routine audio-visual communication, it would be necessary to prioritize ongoing proximity awareness-raising. This strategy could mainly involve resources already mobilized in the DRCongo National Health System, such as community relay agents, who usually raise awareness in the neighborhoods where they are based. The challenges to be addressed here are accessibility to audio-visual communication channels by all levels of the community, the integration of local languages, the participation of accepted community sensitizers and the organization of surveys to gather feedback on the response, rumors and misinformation’s. In this regard, managing rumors and community expectations is a key component of health risk communication. Among the expectations of the population, there is the need to have proof of cases of COVID-19 experienced in their community in order to believe in its existence. When asked about these expectations, we collected the following information: "Give us really palpable evidence to finally convince us to really know what's going on, and that will put us in a state of confidence" (excerpt from an interview with a drug seller, Bukavu/DRC, July 2020). Likewise, one student shared the following: "I can never encourage others to follow these measures because I have never seen a person with corona. I only hear rumors, really I have no definite answers, but I only know that corona is elsewhere in the world. Here at home, I don't really believe it, I base myself on information I don't trust. I really don't know for sure...." (extract from an interview with a student, Bukavu/DRCo, July 2020). A personal caregiver from the COVID-19 response committee added that: "We also need, as I said, to bring people who will give testimonies because they have suffered from covid19 and not just any person. People who are well known and from the community. For example, if there are confirmed cases in the 3 communes of Bukavu, you shouldn't bring someone from the commune of Kadutu to give a testimony in the commune of Bagira, when there is another one in the same commune. Otherwise, no one would believe it" (extract from an interview with a health worker from the COVID-19 response committee, Bukavu-RDC, July 2020). From the above, communicating experiences of COVID-19 cases is an important component in the engagement and acceptability process. However, there needs to be a transparent organization of testimonies about local experiences of the pandemic, to prevent possible perverse effects. One example is the rumors about the orchestration of false testimony of cases of COVID-19. In addition, there is a need to communicate on the expected impact of the response measures so that people understand the importance of adhering to them. Community opinion in Bukavu has perceived some of the response committee's interventions as illogical, and as having been copied from the example of other countries that have applied them. This reflects the need to raise awareness of the relevance of response measures adapted in the countries of the South. Such as the importance the measure of closing schools without closing churches and markets. In the case of Bukavu, for example, the decision to close schools and universities in order to reduce the rate of contamination generated a great deal of resistance. That because at the same time, overcrowded activities such as markets and churches were maintained to preserve sources of income for the population living in the informal sector. Also in several context community claimed to be consulted on about the design of restrictive measures to be implemented. That is the case of the survey of Smith et al. were the participants expressed that there should be allowances to determine what is deemed to be an acceptable risk at the community level; for example, holding a funeral, which may be detrimental for the greater good but actually beneficial for the community ( 6 ). With regard to the above analyze, here is an example of an opinions expressed by our informants and summarized in the Table 6 : "Churches and schools are closed, but markets remain open and are usually much more frequented than churches and schools. We should therefore step up awareness-raising in the markets and equip them with a sufficient number of prevention devices. Or adopt new strategies that would limit the frequency. Some before noon, others in the afternoon. Then, reopen schools and churches too, with certain restrictions such as the wearing of masks, hand-washing, social distancing, etc.” (extract from an interview with a resident of the Ibanda commune, Bukavu/DRC, July 2020). 4.5.4 The organization of public order services to monitor barrier measures against the COVID-19 At both global health and DR Congo levels, analysis of the context of COVID-19 management has led to the need to apply restrictive response measures against certain fundamental freedoms. This is in accordance with the logic of utilitarian justice, one of the usual principles in public health, which prioritizes strategies and actions aimed at guaranteeing the well-being of the huge majority of the population ( 25 ). A closer examination of public health action, however, reveals a lack of explicit robust justification for the use of restrictive measures—because the dominant utilitarian approach of epidemiology and the rights based approach of law do not pay adequate attention to moral considerations such as reciprocity relevant to the overall permissibility of such interventions ( 3 ). In fact, the scale of effectiveness of the response to COVID-19 depends on the application of barrier measures, many of which are restrictive (such as confinement, social distancing, wearing masks, etc.), and so their application requires the application of monitoring and incentives by public order services. In a number of cases experienced in Bukavu, the lack of continuous action by the public order services was one of the major causes of the breakdown in the application of control measures at COVID-19. While Consequences such as fines and community service were documented to be important for those who do not comply with restrictive measures. The approaches used to incentivize the adoption of response measures are apparently weakening the population's participation. Throughout Bukavu, there were many cases of individual or collective resistance to the application of the control measures called for by the police (Table 6 ). These included protest walks and street clashes between police officers and the population during the application of incentives to comply with control measures. One such incident occurred on Tuesday June 16, 2020, in the Bagira commune of Bukavu. This took place after the murder of a taxi driver. The victim was shot by a policeman after a long dispute over the wearing of a nose cover. Following this, the young people of Bagira launched an angry protests, throwing projectiles at the building housing the Covid-19 treatment center located in Bagira commune of Bukavu Town. Another example can be seen in a video taken in Bukavu, in which a woman opposes an arrest by a police officer for not wearing a mask. This resistance led to a fight, simply because the police officer was not wearing a mask either. This situation shows us that the role of surveillance and enforcement of incentives by order services has faced several challenges. These include (i) the scarcity of resources to implement incentives adapted to the conditions of the population. (ii) Lack of compliance models among law enforcement officers. (iii) Accessibility constraints due to shantytown urbanization and lack of adequate traffic links. In the same context, there are informal facilities where people gather, such as markets, bars, family and cultural gatherings, which are inaccessible to the public order services. (iv) Also, from the outset, the actions of the public order services have been insufficient to ensure security in this part of the DR Congo, where there has been a crisis of insecurity for decades. Indeed, as part of the multi-sectoral response and the approach to responses integrating all sectors likely to influence the response, it emerges that the effective organization of public order services is a pillar in the implementation of mandatory response measures. 4.5.5 Gaps in the organization of the healthcare system and certain legacies of the management of the Ebola epidemic in DR Congo The organization of the system for the detection, control and prevention of infections is a pillar of risk management for emerging infectious diseases. Firstly, rapid detection of emerging infectious diseases is essential to minimize morbidity, death and economic losses. Continuous and systematic public health surveillance of the collection, analysis, interpretation and dissemination of health data is a major pillar. Secondly, to ensure capacity for routine control functions, we need to ensure rapid laboratory development, conduct epidemiological investigations and other responses to difficult and complex public health problems. Also, the prevention of emerging infectious diseases requires the use of approved tools ( 26 ). The Infectious Disease Vulnerability Index (IDVI) indicates a health system's ability to monitor and control emerging diseases. DR Congo's IDVI is among the lowest in the world, compared with the system's capacity in terms of surveillance systems, laboratories, hospitals, health insurance systems, organization of emergency health response services, etc.( 28 ). In the case of South Kivu, there is a gap between the COVID-19 response actions communicated by the public authorities and the practical practicability of infectious disease surveillance and response. Indeed, the Governor of the province of South Kivu indicated in his March 30 communication that: "...the province has already taken protective measures which are being reinforced to spare our population from the risk of contamination...". Indeed, without the fundamentals of health risk management, the strategies communicated by South Kivu's public authorities were in vain. Moreover, given the persistence of risk factors for the emergence of infectious diseases (close contact between human and animal environments, international transport flows, biosafety risks, etc.), there is a need to prioritize investment in in-depth infectious disease control actions (detection, control and prevention systems, as well as social and health security). Furthermore, learning from the management of previous epidemics such as the 10 Ebola episodes in DR Congo has enabled the system to better organize the response to COVID-19. Nevertheless, the community's perceptions of the health system's management of previous epidemics has influenced the community's understanding of the origin of the diseases, its confidence in the management authorities and its adoption of response actions. There was a perception that the incidence of the COVID-19 pandemic was a strategy for the Congolese government to mobilize funds by establishing links with the cases of the Ebola epidemic known as "Ebola business", of which the country was at the same time experiencing 10 epidemic episodes. The are evidences of poor management of Ebola outbreak. 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. Therefore, the population was quick to accuse the national and provincial governments of taking advantage of the pandemic to benefit from funds from international institutions. A number of anecdotes have emerged to describe this, including "Cop" or "Dili" in Bukavu common speech to signify a non-transparent, informal affair or business. One of the Bukavu baron's lawyers tells us: "[...] I see, for example, that for Ebola we used to speak of Ebola montage, Ebola Business, Ebola Cop, and so on. When the coronavirus disease was declared in Kinshasa, it was said that there had been a handover and takeover between Ebola and Covid19 " (extract from an interview with a lawyer, Bukavu/DRC, July 2020). 5 Discussion The social media report of the COVID-19 burden abroad and the sporadic compliance with the response measures The main influence of the social media was the perception that the DR Congo health system would have found it difficult to respond to the COVID-19 epidemic compared to the difficulties encountered in the management of COVID-19 in the countries of the North. Despite many challenges (high level of poverty, high population density and relatively fragile health system, etc.), African countries has shown capacity in its response to the pandemic. This may be related to the continent’s experience in responding to several infectious disease outbreaks such as Ebola disease, Lassa fever and cholera ( 28 ). Author way, if well structured, the communication through social networks building mainly on the risk of mortality and aiming at shocking consciences has a great potential for community engagement. According to Kharrat, in a situation of major and diverse challenges namely security, socia and economic challenge, persuasive communication based on emotions can be applied. Emotions are not limited to raise fear or anxiety in this campaign, they also serve to facilitate collective awareness of the extent of the burden and lead to an emotional involvement of citizens who will be more receptive to the arguments and prescriptions of public authorities ( 29 ). Also, social networks and media have become undeniable tools of online communication and this makes them an important part of communication strategies. The strong point of social networks is interactivity. In times of crisis, many organizations have turned to social media as their main communication tool for economic and profit-making reasons. Indeed, social media allows to reach a very large audience at extremely low or no cost ( 30 ). The alert du to the first cases of COVID-19 and the related communication seems to have influenced positively the adherence to the response measures at a given time. Indeed, following the first outreach on the first two cases of COVID-19 in Bukavu, prevention practices were sometimes observed. One of the most important and effective public health strategies for dealing with a pandemic such as coronavirus is to communicate proactively about what is known, what is not known, and what is being done in order to increase awareness, with the aim of saving lives and limiting negative consequences ( 31 ). In addition to build trust, risk communication interventions must be linked to functional and accessible services, be transparent, be well-timed, be simple to understand, acknowledging uncertainties, address affected populations, and be disseminated through different channels, methods, and platforms ( 32 ) . Inadequacies in the response coordination and socio-financial barriers for adopting barrier measures Some weaknesses in coordination have been unfavorable to community engagement in the response. A review of reports of the national response to the COVID-19 pandemic in Africa reported that the key challenges included low public confidence in governments, inadequate adherence to infection prevention and control measures and shortages of personal protective equipment. Also the inadequate laboratory capacity, inadequate contact tracing, poor supply chain and logistics management systems, and lack of training of key personnel at national and subnational levels ( 33 ). Also, in the survey setting in Bukavu City, the majority of the population lives beyond the psycho-social trauma caused by the decades of armed conflict in this region, which has led to the collapse of the population incomes. The results of Koudjom et al. has showed a positive and significant relationship between poverty and the spread of COVID-19 and suggested that more attention needs to be paid to poor populations in African countries during the pandemic. These populations are generally vulnerable, and there is a need for support programs targeting them to be put in place ( 34 ). Need for ongoing communication and application of incentives for response adherence According to the expectation of the study population, the shortcomings of mass communication include the lack of addressing the people’s concerns, not adapted communication channels and to not communicating the impact (Side and positive) of the response measures so that people understand the importance of adhering to them. According to the CDC Field Epidemiology guide, during an outbreak, public health officials must quickly determine the communication purpose, the persons and populations most in need of information and guidance, ways to engage with news media and the public, and ways to gauge the effects of messages and materials ( 35 ). Beside, during our study, interviewers have expressed rumors, misinformation, need of information related to the COVID-19 management. Relating to infodemic, health communication that starts by fostering well-being and basic human psychological needs has the potential to cut through the infodemic and promote effective and sustainable behavior change during such pandemics ( 10 ). World Health Organization recommend to achieve the infodemic management through the following 4 types of activities: listening to community concerns and questions, promoting understanding of risk and health expert advice, building resilience to misinformation and engaging and empowering communities to take positive action. In a number of cases experienced in Bukavu, the lack of continuous action by the public order services was one of the major causes of the breakdown in the application of control measures at COVID-19. Although its relevance, for public health to restrict liberties, observes Callahan, it must provide solidly based factual evidence, in other words, provide objective, scientific, hard facts to validate decisions that override autonomous decision making ( 36 ). Indeed, the modelling analysis of the restrictive measures Impact on the disease spread showed that the countermeasures taken, although they are tough and restrictive, have an effective effect on reducing the rate of spread of the infection ( 37 ). A literature review research confirmed that in countries where anti-pandemic measures were rapidly and consistently in place, the spread of the virus was suppressed more rapidly and the first wave of pandemics in these countries was incomparably more benign than in countries with later responses and milder restrictive measures ( 38 ). While consequences such as fines and community service were found to be important for those who do not comply with restrictive measures, Smith et al., have reported that there ought to be no consequences in the absence of reciprocal arrangements, as in such cases individuals may be put in a position where they have no choice but to not comply with restrictive measures ( 6 ). Gaps in the health preparedness capacity The results of our survey according to the gaps in the health preperadness system is similar with other research funding’s in Africa settings. Capacity to detect and respond to epidemics and pandemics is weak in West and Central Africa and Southeast Asia, regions known to have high risk for emergence of pathogens with pandemic potential ( 39 ). Health systems in Africa were inadequately prepared for the pandemic, and its impact was substantial. Responses were slow and did not match the magnitude of the problem. ( 40 ). During the COVID-19 pandemic, resources to prevent COVID-19 were limited like precaution products, such as medical masks, disinfectants, alcohol-based hand rub and access to running water, especially at publicly managed facilities and facilities in rural areas ( 41 ). Also, the testing capacity in African countries was very low. Most of the countries on the very low capacity need to scale up rapidly ( 42 ). The COVID-19 pandemic have reduced patient flow or limited access to health services in Africa ( 43 ). Jensen and McKerrow have reported during the COVID-19 pandemic significant declines for clinic attendance and hospital admissions of children age < 5 years and a 47% increase in neonatal facility deaths in South Africa ( 44 ). Conceptual framework of health system preparedness for EIDs comprised six health system constructs, including four hardware constructs: Surveillance, Infrastructure and medical supplies, Workforce, and Communication mechanisms; and two software constructs: Governance, and Trust ( 45 ). 6 Conclusion This works have described the different dynamics in the community compliance with COVID-19 first wave response measures, in South-Kivu, DR Congo. For organizational learning, analyse cases of non-compliance with COVID-19 measures are made. These cases are influenced mainly by the inadequacies in the response organization (coordination, risk communication, laboratory capacity, prevention, education, etc.), the socio-financial counter-motivation for adherence, the lake of continuous initiatives, the gaps in the health system structure and the negative legacies of the management of previous epidemic in DR Congo. 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 COVID-19 response explored should benefit from the integrate complementary strategies. This strategies could be the accompaniment of the most disadvantaged people, continuous sensitization, the application of incentives to respect the response measures. Also, to achieve the infodemic management through the following activities: listening to community concerns, promoting understanding of risk, building resilience to misinformation and empowering communities to take positive action. Capacity to detect and respond to epidemics is weak in Democratic Republic of the Congo. The initiatives to strengthen the health system preparedness require to improve capacities including: surveillance, infrastructure and medical supplies, workforce, communication mechanisms, governance, and trust. 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 Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on request. Competing interests The authors declare that they have no competing interests. Funding None Clinical trial number Not applicable.’ Authors' contributions C.A.I. have designed the work, interpret the date and applied per review revisions. P.K.B. have collected the data and interpret the data. G.M.M, B.N.A, J.M.B. E.E.G, J.B.M., B.Z.A and I.B.E have collected the data. Y.C. have drafted the work and revisit it. All authors have reviewed and approved the final manuscript. References Stephen J, McKinney S, Parhi R, Kumar H, Shifau, Gray P. What have we learned about closures of education institutions during the sars outbreak of 2003 and the covid-19 pandemic? Research Papers Presented at the 8th LSME International Research Conference on ‘Sustainable Development and Education’. Published in 2022. 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Googlebook. https://books.google.cd/books?hl=en&lr=&id=1NcK4BEltEQC&oi=fnd&pg=PA1&dq=utilitarisme+en+sant%C3%A9+publique+pdf&ots=Is65YH-RXp&sig=D6INOQKnT55mnF8TOt72_fknFXA&redir_esc=y#v=onepage&q&f=false.Consulté le 24, mars, 2020 Binder S, Levitt AM, Sacks JJ, Hughes JM. Emerging infectious diseases: Public health issues for the 21st century. Science. 1999. https://doi.org/10.1126/science.284.5418.1311 . (80-.). Wolrd health Organisation. Joint external evaluation tool: International Health Regulations. 2022. Avaible on: https://www.who.int/publications/i/item/9789240051980 . Consulted on 25/06/2023. Akande CLO, Oyebanji O, Ogunbode OA, Atteh R, Okwor T, Oguanuo E, Ojumu T, Ofoegbunam C, Ebhodaghe B. Gbenga Joseph, Priscilla Ibekwe, Chikwe Ihekweazu. ‘Fighting a Global War Using a Local Strategy’: contextualism in COVID-19 response in Africa. BMJ Innov 2021;7:347–355. 10.1136/bmjinnov-2020-000637 Kharrat D. Le recours aux émotions dans une campagne de communication publique sécuritaire: Analyse sémiologique des spots. UNIVERSITE DE PARIS –SORBONNE; 2016. Fonds Européen de Développement Régiona. L’utilisation des media sociaux dans la communication. 2020. Avaible on: https://ec.europa.eu/regional_policy/projects/projects-database/using-social-media-to-improve-citizen-engagement-in-european-cities_fr . Consulted on: 12/3/2022. World Health Organisation. Communication sur les risques et participation communautaire (‎ RCCE)‎: préparation et riposte face au nouveau coronavirus 2019 (‎ 2019-nCoV)‎: lignes directrices provisoires, 26 janvier 2020 2019, 1–8. Availble on: https://iris.who.int/handle/10665/330679 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 . Consulted on 5/10/200. Talisuna A, Iwu C, Okeibunor J, et al. Assessment of COVID-19 pandemic responses in African countries: thematic synthesis of WHO intraaction review reports. BMJ Open. 2022;12:e056896. 10.1136/bmjopen-2021-056896 . Etayibtalnam Koudjom Sévérin, Tamwo, Kof D, Kpognon. Does poverty increase COVID-19 in Africa? A cross-country analysis. Health Econ Rev. 2022;12:51. https://doi.org/10.1186/s13561-022-00399-3 . Abbigail J, Tumpey D, Daigle, Nowak G. Communicating During an Outbreak or Public Health Investigation. The CDC Field Epidemiology Manual. AUGUST 8, 2024. Beauchamp D, Steinbock B. New Ethics for the Public’s Health. Oxford, United Kingdom: Oxford University Press; 1999. p. 21. Nikita Andriyanov and Dmitry Korovin. Analysis of the Restrictive Measures Impact on the Disease Spread. International Conference on Information Technology and Nanotechnology (ITNT). IEEE. 2021. 10.1109/ITNT52450.2021.9649210 Dagmar, Dzúrová. Viktor Květoň. How health capabilities and government restrictions affect the COVID-19 pandemic: Cross-country differences in Europe. Appl Geogr Volume. October 2021;135:102551. Oppenheim B, Gallivan M, Madhav NK, et al. Assessing global preparedness for the next pandemic: development and application of an Epidemic Preparedness Index. BMJ Glob Health. 2019;4:e001157. 10.1136/bmjgh-2018-001157 . Tessema GA, Kinfu Y, Dachew BA, et al. The COVID-19 pandemic and healthcare systems in Africa: a scoping review of preparedness, impact and response. BMJ Global Health. 2021;6:e007179. 10.1136/bmjgh-2021-007179 . Bajaria S, Abdul R. Preparedness of health facilities providing HIV services during COVID-19 pandemic and assessment of their compliance to COVID-19 prevention measures: findings from the Tanzania Service Provision Assessment (SPA) survey. Pan Afr Med J. 2020;37:18. Otitoloju AA, Oluwole EO, Bawa-Allah KA. Preliminary evaluation of COVID-19 disease outcomes, test capacities and management approaches among African countries. medRxiv 2020;20103838. Abdela SG, Berhanu AB, Ferede LM, et al. Essential healthcare services in the face of COVID-19 prevention: experiences from a referral hospital in Ethiopia. Am J Trop Med Hyg. 2020;103:1198–200. Jensen C, McKerrow NH. Child health services during a COVID-19 outbreak in KwaZulu-Natal Province, South Africa., Afr Med S, Mohammed J, Oljira H, Roba L et al. KT, Containment of COVID-19 in Ethiopia and implications for tuberculosis care and research. Infect Dis Poverty. 2020;9:131. Palagyi A, Ben J, Marais S, Abimbola SM, Topp ES. McBryde and Joel Negin. Health system preparedness for emerging infectious diseases: A synthesis of the literature. Global public health 2019, VOL. 14, NO. 12, 1847–1868 https://doi.org/10.1080/17441692.2019.1614645 Table 3 Table 3 is not available with this version. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6502452","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":487876118,"identity":"a2c3ac51-a2d0-459c-a44c-ae1ee903610e","order_by":0,"name":"Christian Ahadi 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09:08:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6502452/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6502452/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95193800,"identity":"a89c6ee6-17dd-4ac2-9474-453d20cd663a","added_by":"auto","created_at":"2025-11-05 10:54:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1817255,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6502452/v1/6803e200-1e12-4232-8cd8-6a7efcc37086.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"How COVID-19 restrictive measures were not implemented in Bukavu, DR Congo: a participatory qualitative case study ","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eRestrictive measures are an important intervention in public health. In the SARS outbreak of 2003 and the Covid-19 pandemic, mass quarantine was employed (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The emergence of extensively drug-resistant tuberculosis (XDR-TB) has also raised the issue of the use of isolative measures (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Justifications for public health action involving restrictive measures have been grounded in different considerations on different occasions; that is, depending on the nature of the contagion and measures in play (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eUpshur have designed a public health ethics framework that identifies 4 principles\u0026mdash;the harm principle, proportionality, reciprocity, and least restrictive measures\u0026mdash;to guide public health intervention (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrograms that are coercive should be implemented only in the face of clear public health need and good data demonstrating effectiveness. For public health to restrict liberties, observes Callahan, it must provide solidly based factual evidence, in other words, provide objective, scientific, hard facts to validate decisions that override autonomous decision making (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRestrictive measures as enables individuals to voluntarily comply requires to be proportional to the threat and implemented along with reciprocal arrangements provided to those affected. Also to be accompanied by open and transparent communication throughout all stages so that citizens can both understand and participate in decision-making (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOn an instrumentalist view of motivation, individuals will be motivated to support and comply with public health measures if there is some direct benefit associated with compliance or sanction for non-compliance with the measures. On a normative view of motivation, individuals will be motivated to support and comply with public health measures if they regard such measures as morally appropriate, as opposed to contributing simply to their self-interest. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). While consequences such as fines and community service were found to be important for those who do not comply with restrictive measures (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccording to the World Health Organization, 2020, RECC 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. 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. It is therefore recommended that systems be put in place to detect and respond to expectations, rumors and misinformation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The goal of risk communication and community engagement (RCCE) is to promote informed choices, foster positive behavioral shifts and uphold trust. It is a vital component of pandemic prevention, preparedness and response. RCCE should aligning communication approaches with community values, norms and cultural context messages can be more persuasive and impactful in promoting desired behaviors (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA review have report that key barriers to effective health communication included misinformation, distrust, limited collaboration, and messaging inconsistency. Major gaps were identified in mass and social media strategies, characteristics of messages, sociocultural contexts, digital communication, rapid response, providers\u0026rsquo; attitude and perception, and information source characteristics (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePorat et al., propose practical guidelines for public health and risk communication as following: (i) create an autonomy-supportive health care climate; (ii) provide choice; (iii) apply a bottom-up approach to communication; (iv) create solidarity; (v) be transparent and acknowledge uncertainty (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A study on risk communication on behavioral responses during COVID-19 in China highlight the fact that the population exposed to risk communication messages were positively associated with engaging in preventive behaviors. Whereas, believing in misinformation were negatively associated with wearing masks when in public. An inadequate supplies of personal protection materials were negatively associated with their outdoor hygiene behaviors (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe study have been carried in South Kivu is one of the poor provinces of DR Congo with almost six out of seven inhabitants live below the poverty line (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This region has a considerably high morbidity and mortality rate of infectious diseases such as malaria, cholera, tuberculosis, measles, bubonic plague, yellow fever, Ebola Virus Diseases, etc. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). at the same time, the rate of non-communicable diseases is on the rise. In this region, the health system has shortcomings (infrastructure, equipment, human and financial resources, etc.) and the rate of access to health care is low. This health system has faced challenges in coping with the COVID-19 pandemic. The DR Congo has developed a strategic plan against the COVID-19 epidemic in line with the control strategies proposed by the WHO (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). There is gab in the evidences that describe about the failure of restrictive measures against covid-19 in fragile systems that have experienced decades of epidemics. This study aim is to analyze the dynamics adherence to COVID-19 restrictive measures in Bukavu town, South Kivu province, in DR Congo. For organizational learning, it is necessary to describe the cases of resistance and non-compliance with COVID-19 restrictive measures.\u003c/p\u003e"},{"header":"2 Objectives","content":"\u003cp\u003eThis case study aims to describe, through a participatory socio-anthropological survey, how COVID-19 restrictive measures were not adopted in Bukavu town, in South-Kivu province, in Democratic Republic of 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. It is a region where living conditions is impacted by decades of armed conflict, political and economic instability. The emergence of COVID-19 in this same context, as well as the application of COVID-19's restrictive contingency measures have resulted into 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 COVID-19 restrictive measures.\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 and participatory approach\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFor this case study, we have used a socio-anthropological survey to collect data (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and inductive analysis to present the qualitative data (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Survey was conducted in the 3 communes of the city of Bukavu town between April and July 2020. An interview guide was established with open-ended questions. On the filed the participatory approach we applied consisted in conduct exploratory surveys was conducted with 17 participants including academics, health professionals including technical agents of the COVID-19 response and community members. The objective was to involve these stakeholders in the study design (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\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 with 86 participants by organizing semi-structured interviews. The interviewed actors were selected through convenience sampling and the saturation of data indicated the sample size (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\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. Additionally, the snowball approach consisted in respondents telling us which of their colleagues they felt would be best-placed to be included in the survey. In order to verify the information and to be able to produce agreed opinions, we were triangulating the opinions collected by the different actors (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eData processing and analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe interview recordings were translated and transcribed. We used the thematic analysis method (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) to progressively present and discuss the survey results by identifying recurring themes in the data sources.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Ethical considerations\u003c/h2\u003e\u003cp\u003eBecause this study involves humans, ethical considerations require that they give their free and informed oral consent. Participant were consulted for their permission to record the interviews. During field data collection; local traditions, folk customs, norms and values have been respected. In addition, the ethical principles of respect for persons, respect for the interests of justice of respondents, and respect for communities have been observed.\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Brief description of the DRC Covid-19 response plan\u003c/h2\u003e\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 multisector plan against the epidemic to ensure an effective response. At the community engagement level, which is one of the key 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 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e4.2. \u003cb\u003eInformation about the study participants and theme explored\u003c/b\u003e\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of respondents interviewed\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eProfession/Occupations\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNumbers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003eCommunes in Bukavu Town\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM Male\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFE Female\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBagira\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eKadutu\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIbanda\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUnformal Drug Sellers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStudents\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSmall shopkeepers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHousehold responsible\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eState Health workers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUnemployed youth\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClinical healthcare providers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHousewives\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdults with no schooling\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLawyers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClinical healthcare providers in the COVID-19 treatment center\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/br\u003e\u003cp\u003e\u003cstrong\u003eTable 2: Themes explored in the interview guide\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003esummarize the questions formulated prior to data collection.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eThemes prior to data collection\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThemes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePerceptions of\u003c/p\u003e\u003cp\u003eCOVID-19\u003c/p\u003e\u003cp\u003eResponse management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCOVID-19 response measure practices\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eKnowledge and perception of COVID \u0026minus;\u0026thinsp;19 diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePerception of restrictive COVID \u0026minus;\u0026thinsp;19 control measures\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSub- themes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositiveand negative aspects of COVID-19\u003c/p\u003e\u003cp\u003eresponse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-COVID 19 response measure problems\u003c/p\u003e\u003cp\u003e-Contrast of compliance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-Existence Recognitions\u003c/p\u003e\u003cp\u003e-Treatment and prevention\u003c/p\u003e\u003cp\u003eimpact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-Mask wearing -Hand sanitizer use\u003c/p\u003e\u003cp\u003e-Confinement\u003c/p\u003e\u003cp\u003e-Lock down\u003c/p\u003e\u003cp\u003e-Travel restrictions\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e4.3. Social media relays of the COVID-19 spread abroad and its influence on the people perceptions\u003c/h2\u003e\u003cp\u003eIn the period following the declaration of the emergence of the pandemic in December 2020 in China, when the DRC had not yet recorded any cases of COVID-19, social media spread an alert about the high contagiousness and the implementation of contingency plans in several countries. The population of Bukavu City percieved these alerts on the emergence of COVID-19 into their own understanding beyond the scientific reality. This situation had influenced the community commitement to the response. During the survey, the following understandings were noted within the community. The table 3 present interviewer\u0026rsquo;s perceptions on the COVID-19 origins and existence.\u003c/p\u003e\u003cp\u003eFirst, a perception among actors that the DR Congo system will find it difficult to respond to the COVID-19 epidemic compared to the difficulties encountered in the management of COVID-19 in the developed countries. This is because health system of Northern countries, perceived as efficient model of management, were already experiencing high morbidity and mortality. Also, the stigmatising information on the pandemic conveyed en masse by social media has been translated into religious beliefs as a bad divine omen to which the population has envisaged solutions of a spiritual nature. A religious believer, a pharmacy assistant, interviewed in her pharmacy said that:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;People die from breathing the \"corona\" in the air in Europe, so here in our country it will be more devastating... It seems that it is a sign of the end of the world, we must pray for God to preserve us from it and be ready for the coming of the Lord\" (excerpt from an interview with a pharmacy assistant-in a dispensary, Bukavu/DRC, July, 2020)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAfrica has 15.3% of the world's registered Muslims, and 23.6% of the total Christians, both of them are increasing steadily (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Asare, 2017, present in a narrative discussion that in Africa, there is spiritual involvement in the treatment of disease and health care. According to this author, the new model of health in African cultures can therefore be considered as biopsychosocial model. The case study on dissociative amnesia illustrates that Africans consider spiritual causes of illness when the diagnosis of an illness is very complex. The spiritual beliefs of African patients should not be dismissed but should be used by health care providers to guide and facilitate clients' recovery from illness.\u003c/p\u003e\u003cp\u003eThe alert of the emergence of COVID-19 and the application of restrictive measures such as confinement of the population have raised concerns about the resources of vulnerable populations. An actor from the informal sector, a shoe repairer, expressed his fear in this sense:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"...it seems that the corona is already in Kinshasa and that we are going to be confined as well, those who have the means are getting food, the rest of us are going to die of hunger\" ( extract from an interview with a shoe repairer, Bukavu/DRC, July, 2020)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIt is a fact that the interactions between socio-cultural influences and the flow of information primarily about the high risk of mortality from COVID-19 has led to an awareness of the existence of the pandemic. But all this without an adequate understanding of the pathogenicity and the importance of measures of prevention.\u003c/p\u003e\u003cp\u003e\u003cb\u003e4.4. Sporadic compliance with the response measures from the the experience of the first cases of COVID-19\u003c/b\u003e\u003c/p\u003e\u003cp\u003eLike a new lifestyle, the massive wearing of masks has marked the streets of the city of Bukavu in the following of the communication of the response measures to COVID-19 by the city authorities. From the above, the media coverage of the risk related to COVID-19 (this risk expressed in the media in terms of \"high morbidity and mortality in the better organized systems of the developed countries, etc.\") has raised awareness of the risk. ) have raised awareness of the fact that the COVID-19 pandemic exists. Apart from the fact that this leads to concerns about the survival resources of the vulnerable in case of application of the very restrictive measures and to spiritual interpretations based on religious beliefs.\u003c/p\u003e\u003cp\u003eAlso, the approach to communicating the health risks associated with the first cases of COVID-19 in South Kivu has influenced the adherence to the response measures at a given time.\u003c/p\u003e\u003cp\u003eIndeed, the first case of COVID-19 was reported in DR Congo (in the capital city of Kinshasa) on March 10, 2020. Fourteen days later, a \"state of health emergency\" was declared by the Presidency of the country. With regard to acceptability to the population, the response plan included strengthening risk communication and community engagement through the strategies mentioned in the previous section. A series of other preventive measures followed, the most restrictive of which was the lockdown. On March 30, 2019, the first two positive cases were declared in the city of Bukavu by the Governor of South Kivu Province. Initially, the established risk communication strategy had a positive influence on the adoption of preventive measures.\u003c/p\u003e\u003cp\u003eFor case in point, the provincial governor, Theo Ngwabidje had stated in a communication:\u003c/p\u003e\u003cp\u003e\"I would like to inform the population of our province on the threat of COVID-19, which is in the national and global news. Indeed, since yesterday 19 March 2020, the province of South Kivu has recorded two cases tested positive for the Coronavirus in Bukavu. Thanks to the vigilance and professionalism of our technical services, the two cases have already been put in isolation, and were, under my personal supervision, during the night, transported to the treatment facilities set up for this purpose\u003cem\u003e\u0026rdquo; (Journal Actualit\u0026eacute;. Cd, 30 mars 2020).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHe further invited the population of South Kivu to remain calm, and to observe hygienic measures in order to limit the spread of the disease:\u003c/p\u003e\u003cp\u003e\"I ask the population to remain vigilant, that they do not panic, because a virus as dangerous as the coronavirus, can not be defeated by fear but rather by the implementation of hygiene measures, and the collaboration of all of us: health professionals, journalist, social communicators, local, national and international NGOs ... The province has already taken protective measures that are being strengthened to protect our population that risks contamination on a large scale, \"he added\u003cem\u003e\u0026eacute; (Journal Actualit\u0026eacute;. Cd, 30 mars 2020).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIndeed, following the first outreach on the first two cases of COVID-19 in Bukavu, prevention practices were sometimes observed. The community awareness that was set up mainly through audio-visual media, awareness campaigns had as key messages: the risk of mortality, social distancing, reporting of suspected cases via a call center, wearing masks, use of disinfectants and suspension of activities likely to cause gatherings (schools, religious cults, weddings, mourning, festivities, sports activities, bar, discotheques, etc.). The Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e present main reactions and attitudes of people to some COVID-19 barriers measures.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReaction to some COVID-19 barriers measures\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme explored\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMain opinion from Data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExemples of citations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSanitary containment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Good measure if it could be respected,\u003c/p\u003e \u003cp\u003e- Impossible given the low socio-economic average\u003c/p\u003e\u003cp\u003e- Good measure if the state helped people to survive\u003c/p\u003e\u003cp\u003e- Useless because not respected\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\"...containment is a formality in Bukavu because it has not been respected, let's uncontain the city and let people learn to live with this virus while respecting the response measures since we are going to die with hunger...\" Phamacy holder, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;That measure of staying at home that might not be possible because of the problems. For example, I spend all day here trying to find a measure of flour to eat every day, but I don't know how I can stay at home when there's no help.\u0026nbsp;\u0026raquo; Responder Without school education, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\"Let's say in a family where both parents are teachers they haven't received anything for over 3 months but you tell them to STAY HOME, to do what then. I don't see how\" Student, Bukavu/RDC, July 2020\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNose Mask\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Good if understood by the public\u003c/p\u003e\u003cp\u003e- Doubts about effectiveness\u003c/p\u003e\u003cp\u003e- Difficult for some\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;the measures would be good but they are not respected, there are those who put their masks on the neck instead of the nose and others don't have any.\u0026nbsp;\u0026raquo; Head of household. Bukavu/RDC, July 2020\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;also I think they did a good job of giving people information about the measures, for example with the nose masks I find a lot of people respect that either for fear of being arrested\u0026nbsp;\u0026raquo; Respondant without school education, Bukavu/RDC, July 2020\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;when we know that the Covid-19's existence is false, why wear a nose mask\u0026nbsp;?\u0026nbsp;\u0026raquo; Student, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;There are also others who can't afford it, so it would be better to help them.\u0026nbsp;\u0026raquo; Student, Bukavu/RDC, July 2020.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSocial distanciation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Good measure but difficult to apply in our context\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;people spend all day at the market being crammed in, yet at church it's less than 3 hours.\u0026nbsp;\u0026raquo; Phamacy holder, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp; Social distancing, first of all, is something I can't say is normal, because you can't tell a person to walk one metre closer, you start walking with a tape measure or whatever, it can't really be done\u0026nbsp;\u0026raquo; Student, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;Social distancing is difficult, at least for us in the DRC.\u0026nbsp;\u0026raquo; Student, Bukavu/RDC, July 2020.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClosing churches and schools\u003c/b\u003e:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Good measure\u003c/p\u003e\u003cp\u003e- A good measure, but it's already been many months\u003c/p\u003e\u003cp\u003e- Unnecessary because markets are always open all day while church doesn't take up as much time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;About schools and churches, I didn't understand how the churches could be closed when you just go in for 1 or 2 hours and then leave, whereas the market is open all day and hasn't been closed. That's when I had a bad thought too, if only the church had problems. We shouldn't have closed it, we shouldn't have closed it because it looks like we're leaving. Why was the all-day market spared?\u0026nbsp;\u0026raquo; Respondant without school education, Bukavu/RDC, July 2020\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;As far as schools and churches are concerned, I don't think we can go on like this. Let's find out who's really going to allow us to start classes and open churches!\u0026nbsp;\u0026raquo; Student, Bukavu/RDC, July 2020\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;First of all, we'll have to ignore this solidarity and Christianity, and respect the barrier measures first. These are the measures that will enable us to get back to normal activities without any problems.\u0026nbsp;\u0026raquo; COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHand washing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-Good mesasure\u003c/p\u003e \u003cp\u003e-Good to prevent other diseaseas a part from COVID-19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;Concerning hand washing is concerned, many people have respected this because you will see people washing their hands before entering health centers; schools, in markets, many have washed\u0026hellip;\u0026nbsp;\u0026raquo; Respondant without school education, Bukavu/RDC, July 2020\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;there are those who still resist, but others who have understood and are beginning to respect the measures to combat this disease.\u0026nbsp;\u0026raquo; Public Health Professional, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;up to now, there are those who neglect the barrier measures and they don't mind because they think it's a \"cop\" or a deal\u0026nbsp;\u0026raquo; Jobless Youth, Bukavu/DRCongo, Jully 2023\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs a result of the communication efforts, many of the study participants described having adequate knowledge and prevention practices:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"There are those who say that the emergence of COVID-19 is an arrangement of a deal by the government that wants to benefit from the financing of the response, but personally I believe that the disease is here, it is spreading worldwide. I mobilize my family to wear face masks and everyone should do the same\" (Father of the family, Bukavu-DRC, April 2020)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Covid19 is a contagious disease that is transmitted through contact, if we don't apply the barrier measures and the lack of adoption it is a reality in Bukavu\" (from an interview with a Drug Vendor in an informal public pharmacy, Bukavu/DRC, April 2020).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn particular, we noted that the experience of the announcement of a confirmed case of COVID-19 in a resident of the Bagira area, in the city of Bukavu, motivated many residents of this area to respect the measures of containment and social distancing as well as the wearing of masks in public places and on public transport. An informant living on the same street as the person who tested positive for COVID-19 told us the following experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"...when our neighbor tested positive for COVID-19, you had to experience the panic and fear of being contaminated, we didn't leave the house for days, we didn't greet each other with our hands, everyone wore masks in Bagira, we respected the distance in the bus.... \". (Student in pharmaceutical science, Bukavu-DRC, July 2021).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe same source told us that:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"... and as the family of the alleged patient felt insecure, they denied it on social networks saying that the person of the family who was returning from a trip from Europe did not have the corona...and progressively with many rumours the tension ceased in Bagira\" (Student in pharmaceutical science, Bukavu-DRC, July 2021).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn addition, with the suspension of incentives, there has been a decrease in the application of preventive measures. We have analyzed in the following part of the article the components of the situation breakdown.\u003c/p\u003e\u003cp\u003e\u003cb\u003e4.5 Breakdown in the application of COVID-19 barrier measures: coordination of the response, communication activities, establishment of incentives, the socio-financial imbalance and t the Health System structure gaps\u003c/b\u003e\u003c/p\u003e\u003cp\u003eHowever, the situation of vulnerability of the population in South Kivu as introduced above, the risk communication implemented and the shock of awareness linked to the incidence of the first cases of COIVD-19 led to a temporal understanding of the risk and the application of preventive measures by the population. Nevertheless, our analyses show that the continuous application of the measures would require complementary strategies such as the accompaniment of the most disadvantaged people, continuous sensitization, the application of incentives to respect the response measures (through the control of public order services, etc.). Also, the transparent coordination of the pillars of the COVID-19 response program such as epidemiological surveillance, prevention and control, laboratory organization, medical and psycho-social care and logistics. These pillars of the COVID-19 response are included in the policies for the fight against COVID-19 in the DR Congo (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) as well as in the global strategy for the fight against COVID-19 whose main goal is that all countries control the pandemic by slowing down transmission and reducing mortality associated with COVID-19 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Based on consultations with key stakeholders in the Bukavu COVID-19 response system, we present shortcomings in the response actions that would have led to the lax application of barrier measures. The Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e summarize the respondent\u0026rsquo;s reactions about the COVID-19 barriers measures.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePerception of COViD-19 origins and existance\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme explored in the survey\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMain opinion from Data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExemples of citations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerceived origin of COVID-19\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- From China\u003c/p\u003e\u003cp\u003e- In the white world\u003c/p\u003e\u003cp\u003e- Annecdotes: Demons, government and/or healthcare staff business, illusion, \"COP\" or \"DILI\" to say a business to make money, a way to enrich themselves for some.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;there are those who say it's a government deal to enrich themselves by funding the response, but personally I don't think that's the case - the disease is real!\u0026nbsp;\u0026raquo; Household head, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;it's one more suffering in our lives and it's coming from the West among the Whites (bulaya) since we didn't know such a misfortune was going to happen to us, children don't study anymore, and those who have studied have no jobs, famine\u0026hellip;\u0026nbsp;\u0026raquo; A display retailer Women, Bukavu/RDC, July 2020\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;as Ebola has made people rich, some have thought that this disease will also enrich those responsible for the response.\u0026nbsp;\u0026raquo;. A display retailer Women, Bukavu/RDC, July 2020\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;COVID-19 is a pandemic that is making the newspapers and affecting all sectors of life. It is said to come from the pangolin in china, but we can't be sure of anything since we have several pieces of information in our possession as to its origin\u0026nbsp;\u0026raquo;. Unemployed youth, Bukavu/RDC, Jully 2020.\u003c/p\u003e\u003cp\u003e\"...It has to be recognized that this is a disease that existed in certain regions of the world, notably in Asia, Africa and the Mediterranean regions of Africa, such as Algeria, Egypt and Tunisia, and now we have the second form of coronavirus that has reached all regions of the world.\" COVID-19 treatment center care personnel, Bukavu/RDC, Jully 2020.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerceived existence of COVID-19\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSome think it exists, others doubt it.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;but I'm thinking that it hasn't arrived here yet, but it's the people who want to make it more severe.\u0026nbsp;\u0026raquo; A responder without school education,, Bukavu/RDC, July 2020\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;we can only believe in his presence here, given the closed schools and churches\u0026hellip;\u0026nbsp;\u0026raquo; Student, Bukavu/RDC, July 2020\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;...Initially, people did not believe in the disease and thought it was a lie or a way for the authorities to get rich, but with the few people who died, the population began to understand...\u0026nbsp;\u0026raquo; Public Health Professional, Bukavu/RDC, July 2020\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e4.5.1 Inadequacies in management: case of the effect of the resignation of Noble Prize winner Dr Mukwege from the COVID_19 response committee in South Kivu\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSome weaknesses in coordination have been unfavorable to community engagement in the response. One illustrative situation is the resignation of Nobel Prize winner Dr Mukwege. Indeed, appointed on 30 March as director of the response commission against the coronavirus by the governor of South Kivu Th\u0026eacute;o Kasi, Dr. Denis Mukwege submitted his resignation on June 2020, stating that the decision to resign was \"in order to devote myself entirely to my medical responsibilities and to treat this influx of patients at Panzi Hospital\" (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In South Kivu, the resignation of Dr. Mukwege (who is presented as an actor trusted by people) has raised suspicions of mismanagement of the response. Congolese political class, public opinion and social networks talked about affairs in the crisis by public actors. This opinion became widespread and maintained that the Covid-19 crisis is no longue a threat but an occasion for the gathering financial resources from international aid. In addition to this, there were various contradictions in the communication of the Covid-19 cases at various levels of management. In this regard, provincial governors were sometimes contradicted by the national response team. This has led to doubts about the veracity of the incidence of the disease in the community. For example, on 3 April 2020, the national authorities published an epidemiological bulletin announcing a third new case in South Kivu. This statement was contradicted on 06 April by the provincial authorities, who stated that it was one of two old cases tested twice by mistake (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs presented in the Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e6\u003c/span\u003e, some informants emphasized the poor management of the response to COVID-19. A resident of the Ibanda commune said:\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFeedback to COVID-19 response management\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme explored\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMain opinion from Data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExemples of citations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResponse activities\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment:\u003c/p\u003e\u003cp\u003e- Good because the cured are talked about\u003c/p\u003e\u003cp\u003e- Doubts about the effectiveness of this treatment\u003c/p\u003e\u003cp\u003e- Bad, since some hospitals charge for treatment of this disease - Bad, since the response manager had resigned\u003c/p\u003e\u003cp\u003eCommunication :\u003c/p\u003e\u003cp\u003e- Ineffective due to lack of trust\u003c/p\u003e\u003cp\u003e- Ineffective in raising public awareness and understanding\u003c/p\u003e \u003cp\u003e- Predominance of rumors and publicity for other organizations or hospitals\u003c/p\u003e\u003cp\u003e- Contradiction and instability in communication activities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;When the coronavirus disease was declared in Kinshasa, it was said that there was a handover between Ebola and Covid-19\u0026nbsp;\u0026raquo; Respondent without school education, BuKavu/DRC, Jully 2023.\u003c/p\u003e\u003cp\u003e\"...in my opinion the management is not good since seeing first of all the person in charge of the riposte the Noble Prize Dr Denis Mukwege resign.\" Phamacy holder, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;Health professionals are raising awareness throughout the city, but some people are not making their task any easier by refusing to comply with barrier measures\u0026hellip;\u0026nbsp;\u0026raquo; \u0026raquo; Public Health Professional, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\"...the response is effective and the government has made available hand washes, hydroalcoholic solutions, soaps, etc. If people respect these measures, we have a chance of getting through this well.\" Public Health Professional, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;In Bukavu they said there were 3 cases, then they said it was cured, but when they found out that there were funds coming from America, they announced again that there were three cases that hadn't been cured. So as far as I'm concerned, there's no covid19 in Bukavu\u0026nbsp;\u0026raquo;. Student, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;And the population, left sadly in its corner, thinks it's all about Covid-19 cases and politicians making money, while hospitals take advantage of the situation to kill people in order to earn money for the survival of their care units. As a result, people will be afraid to come to the hospital for treatment.\u0026nbsp;\u0026raquo; COVID-19 treatement center care woker, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;The street demonstrations in Bukavu are very alarming, because I saw people protesting at the covid19 treatment center in Bukavu, breaking the windows and saying they wanted to free the patients who were there.\u0026nbsp;\u0026raquo; COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;...Also, concerning the communication on the number of cases, the provincial secretariat of the response team gives a number while the lab in Bukavu gives a different number.\u0026nbsp;\u0026raquo; COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;About management I'm going to assume that our province was on the right track with only one covid management center but unfortunately I don't know if it's greed or not, they decided to keep COVID positive people in hospitals and so there were outbreaks so that 40 percent of the nursing staff were affected.\u0026nbsp;\u0026raquo; COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEncourage people to follow response measures\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Communicate the importance of these measures\u003c/p\u003e\u003cp\u003e- Set an example\u003c/p\u003e\u003cp\u003e- Make it mandatory and impose fines and arrests on those who fail to comply with these measures.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;I have to set an example for them, starting with my children and my husband, but also show them that the consequences of neglecting these measures are bad\u0026nbsp;\u0026raquo;. Display retailer Women, Bukavu/RDC, July 2020\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;is by preaching by example, washing our hands and above all respecting social distancing\u0026hellip;\u0026nbsp;\u0026raquo; Public Health Professional, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;if there was help like there was in other countries, we too could stay indoors. Because we learned that in other places (countries) like Tanzania they gave them 60 kg of rice, flour, beans as well as sugar and salt...\u0026nbsp;\u0026raquo; Respondant without school education, Bukavu/DRCongo, july 2020\u003c/p\u003e\u003cp\u003e\"What I'm proposing is that they collaborate with the public because they may have ideas, but the public may also have ideas that would enable us to live with covid19.\" Student, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;Force won't do any good because people will change the way they bypass them. I think the best way to do this is just to work on people's awareness.\u0026nbsp;\u0026raquo; Health care professionnal, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\"Providing food to some of the poor ( poor people) will alleviate the most sensitive economic problems.\" Health Professional, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;First of all, I don't think it should be obligatory, but rather that people should be made aware of the dangers of COVID 19.\u0026nbsp;\u0026raquo; Lawer, Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImproving response management\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Keep up the pace of awareness-raising\u003c/p\u003e \u003cp\u003e- Collaborate with the population\u003c/p\u003e\u003cp\u003e- Help people with hand-washing devices and nose masks\u003c/p\u003e\u003cp\u003e- Integrate people who are qualified and competent into the response team\u003c/p\u003e\u003cp\u003e- Put their oath as healthcare workers before anything else\u003c/p\u003e\u003cp\u003eset up a covid19 testing laboratory in each commune of Bukavu\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;ask the provincial authorities and their team to involve intellectuals in the response, because many of those we meet in the field have not studied\u0026hellip;\u0026nbsp;\u0026raquo; Household head, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;to be close to the community living with this virus,\u003c/p\u003e\u003cp\u003eit's really important that the community finds a space to express itself and that their cries are taken into consideration.\u0026nbsp;\u0026raquo; Unemployed youth, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;We don't trust them, we don't trust our governors, which is why it would be really difficult to apply everything they tell us, despite what they've done, with TV and radio campaigns.\u0026nbsp;\u0026raquo; Student, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;They've already revealed everything, and we know that they're after money, and that's very clearly visible. I don't think we can trust them anymore, despite what we may say\u0026nbsp;\u0026raquo;. Student, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003eConcerning barrier measures, I think there's also a problem of awareness. Even nursing staff find it hard to wear a nose mask all day long, so how do you expect non-healthcare staff to manage without having properly explained the benefits of this mask to them? COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;We really need to rethink our communication methods, the types of ads to run on the radio and the types of messages to be conveyed. We need to know what message to get across, and who can get that message to people.\u0026nbsp;\u0026raquo; COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;The clarity in their publication and the precision with supporting evidence because we are not an illiterate population.\u0026nbsp;\u0026raquo; Health Professional. Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"The management would seem to be working well but after considering Denis Mukwege's resignation first of all. The reasons for his resignation are his own, but we believe that it is because he did not get along with his colleagues due to the fact that there was funding managed inappropriately\u0026hellip;. All these measures are not important because there is no COVID, I don't really agree, these measures are to distract people\" (extract from an interview with an inhabitant of the commune of Ibanda, Bukavu/DRC, July 2020).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOn the other hand, concerning the management of COVID-19 in the city of Bukavu, while the population stayed suspicious of the presence of COVID-19 and the application of prevention measures. This annoyed public authorities who were too confused by the epidemiological context. Of the most important, the provincial governor, Th\u0026eacute;o Ngwabidje, expressed his anger in passing:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"Bukavu, shiye bote tuko bayuwayi\", he said in Swahili, all indignant. Translation: \"Everyone thinks he is an expert in Bukavu\".\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOn social networks, the famous sentence of the provincial governor caused a buzz and was used by several internauts to criticise his various decisions in the management of COVID-19. From this, it was clear that the activities of the implementation of the response had contributed to confusion in people's understanding of COVID-19. At the outbreak of the epidemic, those who were on alert and in doubt had raised their awareness by respecting certain barrier measures (hand washing, wearing of masks, use of hydro-alcoholic gels, etc.). Subsequently, they stopped making the effort due in part to a loss of trust in the public authorities and the health system (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e6\u003c/span\u003e). One Health care worker said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"...if there is no appropriate and honest communication there is no trust. Even worse if there is bad communication or lies there is destruction and unfortunately this is our context. Yes, we are confuse\" (extract from an interview with a health care worker, Bukavu-DRC, July 2020).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e4.5.2 Socio-financial barriers as a counter-motivation to implementation of COVID-19 measures\u003c/h2\u003e\u003cp\u003eWhen covid-19 occurred, the DRC was going through a period where the new government invested in January 2019 was in the process of setting up new projects to stabilise the political, economic and security situation. It was in this context that the country hosted COVID-19, thus disrupting all sectors of the country. The socio-financial situation of the population of Bukavu was an obstacle to the actions against COVID-19. In this region, the population lives in survival terms beyond the psycho-social trauma caused by the decades of armed conflict in this region, which has led to the collapse of the population's income. In this context, where the majority of the population lives off the land in the informal sector, response measures such as social distancing, confinement, the state of emergency, border closures, urban-rural isolation, etc. have paralysed their activities. The introduction of these measures had been inspired by foreign experiences where the context allowed the population to adopt them. This was in contrast to the context of the DR Congo where these measures should be rethought with regard to the direct (mortality and morbidity) and indirect (loss of resources, etc.) pathological burden of COVID-19. This is why it was not easy for the population to appropriate and adopt these measures, which for them disrupted their daily lives. COVID-19 is indeed a issue that has arisen in the context of other more preoccupying health and economic problems. One of the the opinions of community actors highlight in the Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e7\u003c/span\u003e were as follows:\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOpinions on COVID-19 socio-economic impacts and community resilient attitudes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme explored in the survey\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMain opinion from Data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExemples of citations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSocio-economic impacts\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIn general, covid is perceived to have a negative impact on the social, economy, \u0026eacute;ducation, etc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp; \"...it comes from China and its impact on my life is more than great, it has made us vulnerable.\"\u0026raquo; Phamacy holder, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;our children who stay at home become thieves and on the economic front the dollar rate rises a lot.\u0026nbsp;\u0026raquo; Head of household. Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;I haven't had a job for 3 years since I finished my studies, and the impact of this disease on my life is very great, since even my parents, who still do everything for me, no longer work as they should\u0026nbsp;\u0026raquo; Unemployed youth, Bukavu/RDC, Jully 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;I see that the Covid is paralyzing everything, even those who work, even shopkeepers no longer sell well\u0026nbsp;\u0026raquo; A responder without school education,, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\"Some activities have decreased and income while other items have increased in price due to the scarcity of products; foodstuffs have increased in price due to the high exchange rate.\u0026nbsp;\u0026raquo; Health professional,, Bukavu/RDC, July 2020.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResilient attitude\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Sporadic comply with COVID-19 barrier measures\u003c/p\u003e\u003cp\u003e- We learned that there are plants that heal\u0026nbsp;: lemon, ecalyptus, avocado leaf, banana leaf, ginger, tetraderma riparia, etc.\u003c/p\u003e\u003cp\u003e- MUVUKE\": a process that consists of heating water containing certain plants, then covering oneself with a thick cloth containing this still-boiling water and inhaling the steam and feeling the heat for as long as possible.\u003c/p\u003e \u003cp\u003e- BIBLE HAIR\": the process of leafing through the Bible in search of a hair, then placing it in a quantity of water to be drunk morning, noon and night.\u003c/p\u003e\u003cp\u003e- Making masks from pagne fabric\u003c/p\u003e\u003cp\u003e- Local production of hydroalcoholic gels\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;But also to show people that it's not enough to just use soap to wash their hands: the cinders can also work\u0026hellip;\u0026nbsp;\u0026raquo; Display retailer Women, Bukavu/RDC, July 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;it's not a disease that's well known traditionally it takes years to think about traditional treatment\u0026nbsp;\u003cb\u003e\u0026raquo;.\u003c/b\u003e Unemployed youth, Bukavu/RDC, Jully 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;the barrier measures in South Kivu are international, so they're effective, and if we're still alive now it's thanks to these measures, which really should be respected if we all want to survive\u0026nbsp;\u0026raquo; Jobless Youth, Bukavu/DRCongo, Jully 2023\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;population may also have ideas that would enable us to live with covid19. AIDS exists and we live with it; we've lived with Ebola and influenza, which are also viral diseases.\u0026nbsp;\u0026raquo; Student,, Bukavu/DRCongo, Jully 2023\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;\u0026hellip;The problem is the solidarity we think we have in our country, we think that to be in solidarity with someone is to be tight to them. But no, we can show solidarity by respecting these measures.\u0026nbsp;\u0026raquo; \u0026raquo; COVID-19 treatement center care woker,Bukavu/DRCongo, july 2020.\u003c/p\u003e\u003cp\u003e\u0026laquo;\u0026nbsp;At the beginning, people used to talk about \"BIBLE HAIR\": they would look for hair in the Bible and mix it with water, then drink that water to avoid covid.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"It is one more pain in our life and it comes from the West among the whites because we did not know that such a disaster was going to happen to us, the children do drop out of school, and those who have studied are not employed, famine is also here\" (extract from an interview with a mother, street vendor, Bukavu, DR Congo, July 2020)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Let's say in a family where both parents are teachers they haven't received anything for more than 3 months? then you tell them to stay at home. So why do they do with STAY AT HOME?,\" (excerpt from an interview with a student, Bukavu/DRC, July 2020)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\" I'm not employed already since I finished my studies 3 years ago. the impact of this disease on my life is very significant because my parents who are still doing everything for me are also no longer working as they used to\" (excerpt from an interview with an unemployed girl, Bukavu/RD Congo, July 2020).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOver time, while the countryside was isolated from the city of Bukavu, the international borders were closed, river transport was stopped, and Bukavu was almost dried out of food. The precarity and growing vulnerability of the population was intensified. These isolated areas were the main suppliers of the city of Bukavu on which many households depend for survival. On the one hand, many people outside the city hold jobs in the city where they are forced to move every day. On the other hand, many of these people provide food in town from which supply and demand are regular (frequent). A health worker said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\" ... Let us also note the economic impact of COVID-19 with the fact that we live at the rate of the day, there is no traffic but rather the closure of certain businesses\" (extract from an interview with a health worker, Bukavu/DRC, July 2020).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFaced with this situation, the population adopted strategies to survive. As a Latin proverb says: \"a hungry man has no ears\"; this was the case in the town of Bukavu where the coordination of the response had experienced several organisational and technical problems. It was also confronted by the context of food insecurity and the vulnerable nature of the majority of the population. Thus, the response measures suffered in several ways, including the following:\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) This new pandemic revealed to the population that it had the capacity to use the available resources to fight the disease. It is in this context that the population had put in place mechanisms and practices for a common fight. These include the practice of Muvuke and the regular consumption of lemon juice. This practice had become widespread in the majority of families in Bukavu until the scarcity and increase in the price of lemon on the market was observed. However, other people remained aloof to these practices with little certainty about their effectiveness. A medicine seller said:\u003c/p\u003e\u003cp\u003e\"So far I have not seen anyone with corona but I see people taking Muvuke only\" (from an interview with a medicine seller, Bukavu/DRC, July 2020).\u003c/p\u003e\u003cp\u003eA student continues:\u003c/p\u003e\u003cp\u003e\"I can say that traditionally you can't treat COVID-19. It's just that nowadays a lot of things are going around. First with the Muvuke system, but for me it is a distraction because this mixture made of lemon, ginger, black pepper and drunk after heating is effective in the said disease. The problem remains on the proof of the mode of action of this portion\" (extract from an interview with a student, Bukavu/DRC, July 2020).\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Most pe ople reported having relied on practices aimed at bypassing the financial problems associated with food supplies. As a result, commercial practices had been disrupted. In terms of rural-urban trade, small traders were opposed to staying at home while the provincial government's decision was already in effect. The decision had been adopted at a provincial council of ministers meeting held on April 1 2020 by the governor, Th\u0026eacute;o Ngwabidje. The decision was taken on three levels: the closing of all ports, airports and aerodromes in South Kivu for the transport of people, with the exception of cargo; the closing of all roads leading to the territories, with the exception of vehicles transporting foodstuffs and other basic necessities; and the ban on navigation on the lake for the transport of people. The local population took steps to continue their activities under the usual conditions, and to escape the government's decision. As for small cross-border traders, they had initially decided to source their supplies in rural areas, but the poor state of the road was a major obstacle. As a result, some sellers have set up a groupage system to obtain supplies in Cuangugu, a town in Rwanda bordering the city of Bukavu.\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Moreover, faced with the lack and high cost of protection kits (masks, hydroalcoholic gel, etc.), local populations developed new practices. All sewing workshops began to make reusable masks for the public and health-care workers, even though these masks were initially considered ineffective by the WHO (WHO, 2020). Other people, including pharmacists, manufactured gels in informal structures; and hand-washing devices were developed by agists. A resident of Bukavu said:\u003c/p\u003e\u003cp\u003e\"[...] and we mustn't wait for the mask to come to us from the whites, we ourselves have to sew them with cloth\" (extract from an interview with a Bukavu resident, Bukavu/DRC, July 2020).\u003c/p\u003e\u003cp\u003eIn the context explained above, in Africa and in Bukavu in particular, maintaining containment had become an arduous task. All the measures that had been adopted had led to many people losing their jobs and becoming unable to survive. And that's why people were resistant to containment and other measures. People's opinions were divided in an African perspective marked by a spirit of solidarity. Benjamin Djoudalbaye, Head of the Health Diplomatic Policy and Communications Division at the African Union's Centre for Disease Control (CDC), explained:\u003c/p\u003e\u003cp\u003e\"We shouldn't apply other people's solutions to our problems. I think we are intelligent enough to find solutions adapted to our African context. Containment should be accompanied by a certain number of measures to mitigate the effects, both on populations and businesses\".\u003c/p\u003e\u003cp\u003eThis is how the measures put in place to limit the spread of the coronavirus, as recommended by the WHO, have made people's way of life more difficult.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e4.5.3 Need for ongoing communication and integration of evidence of COVID-19 experience\u003c/h2\u003e\u003cp\u003eThe risk communication initiatives put in place have not helped to maintain compliance with barrier measures. First of all, the key messages of health risk communication lack several elements that the public has expressed to us in the form of information needs. In addition, the community's opinion gave more importance to subjects missing from the communication, such as curative treatments, the recurrence of the disease, the pathology's particularities in relation to races, and the expected maximum duration of the crisis. This points to the need for risk management to take account of community feedback gathered through surveys. On the other hand, the communication channels used were not adapted to the local context. In addition to routine audio-visual communication, it would be necessary to prioritize ongoing proximity awareness-raising. This strategy could mainly involve resources already mobilized in the DRCongo National Health System, such as community relay agents, who usually raise awareness in the neighborhoods where they are based. The challenges to be addressed here are accessibility to audio-visual communication channels by all levels of the community, the integration of local languages, the participation of accepted community sensitizers and the organization of surveys to gather feedback on the response, rumors and misinformation\u0026rsquo;s.\u003c/p\u003e\u003cp\u003eIn this regard, managing rumors and community expectations is a key component of health risk communication. Among the expectations of the population, there is the need to have proof of cases of COVID-19 experienced in their community in order to believe in its existence. When asked about these expectations, we collected the following information:\u003c/p\u003e\u003cp\u003e\"Give us really palpable evidence to finally convince us to really know what's going on, and that will put us in a state of confidence\" (excerpt from an interview with a drug seller, Bukavu/DRC, July 2020).\u003c/p\u003e\u003cp\u003eLikewise, one student shared the following:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I can never encourage others to follow these measures because I have never seen a person with corona. I only hear rumors, really I have no definite answers, but I only know that corona is elsewhere in the world. Here at home, I don't really believe it, I base myself on information I don't trust. I really don't know for sure....\" (extract from an interview with a student, Bukavu/DRCo, July 2020).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA personal caregiver from the COVID-19 response committee added that:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"We also need, as I said, to bring people who will give testimonies because they have suffered from covid19 and not just any person. People who are well known and from the community. For example, if there are confirmed cases in the 3 communes of Bukavu, you shouldn't bring someone from the commune of Kadutu to give a testimony in the commune of Bagira, when there is another one in the same commune. Otherwise, no one would believe it\" (extract from an interview with a health worker from the COVID-19 response committee, Bukavu-RDC, July 2020).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFrom the above, communicating experiences of COVID-19 cases is an important component in the engagement and acceptability process. However, there needs to be a transparent organization of testimonies about local experiences of the pandemic, to prevent possible perverse effects. One example is the rumors about the orchestration of false testimony of cases of COVID-19.\u003c/p\u003e\u003cp\u003eIn addition, there is a need to communicate on the expected impact of the response measures so that people understand the importance of adhering to them. Community opinion in Bukavu has perceived some of the response committee's interventions as illogical, and as having been copied from the example of other countries that have applied them. This reflects the need to raise awareness of the relevance of response measures adapted in the countries of the South. Such as the importance the measure of closing schools without closing churches and markets. In the case of Bukavu, for example, the decision to close schools and universities in order to reduce the rate of contamination generated a great deal of resistance. That because at the same time, overcrowded activities such as markets and churches were maintained to preserve sources of income for the population living in the informal sector. Also in several context community claimed to be consulted on about the design of restrictive measures to be implemented. That is the case of the survey of Smith et al. were the participants expressed that there should be allowances to determine what is deemed to be an acceptable risk at the community level; for example, holding a funeral, which may be detrimental for the greater good but actually beneficial for the community (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). With regard to the above analyze, here is an example of an opinions expressed by our informants and summarized in the Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e6\u003c/span\u003e:\u003c/p\u003e\u003cp\u003e\"Churches and schools are closed, but markets remain open and are usually much more frequented than churches and schools. We should therefore step up awareness-raising in the markets and equip them with a sufficient number of prevention devices. Or adopt new strategies that would limit the frequency. Some before noon, others in the afternoon. Then, reopen schools and churches too, with certain restrictions such as the wearing of masks, hand-washing, social distancing, etc.\u0026rdquo; (extract from an interview with a resident of the Ibanda commune, Bukavu/DRC, July 2020).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e4.5.4 The organization of public order services to monitor barrier measures against the COVID-19\u003c/h2\u003e\u003cp\u003eAt both global health and DR Congo levels, analysis of the context of COVID-19 management has led to the need to apply restrictive response measures against certain fundamental freedoms. This is in accordance with the logic of utilitarian justice, one of the usual principles in public health, which prioritizes strategies and actions aimed at guaranteeing the well-being of the huge majority of the population (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). A closer examination of public health action, however, reveals a lack of explicit robust justification for the use of restrictive measures\u0026mdash;because the dominant utilitarian approach of epidemiology and the rights based approach of law do not pay adequate attention to moral considerations such as reciprocity relevant to the overall permissibility of such interventions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In fact, the scale of effectiveness of the response to COVID-19 depends on the application of barrier measures, many of which are restrictive (such as confinement, social distancing, wearing masks, etc.), and so their application requires the application of monitoring and incentives by public order services.\u003c/p\u003e\u003cp\u003eIn a number of cases experienced in Bukavu, the lack of continuous action by the public order services was one of the major causes of the breakdown in the application of control measures at COVID-19. While Consequences such as fines and community service were documented to be important for those who do not comply with restrictive measures. The approaches used to incentivize the adoption of response measures are apparently weakening the population's participation. Throughout Bukavu, there were many cases of individual or collective resistance to the application of the control measures called for by the police (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e6\u003c/span\u003e). These included protest walks and street clashes between police officers and the population during the application of incentives to comply with control measures. One such incident occurred on Tuesday June 16, 2020, in the Bagira commune of Bukavu. This took place after the murder of a taxi driver. The victim was shot by a policeman after a long dispute over the wearing of a nose cover. Following this, the young people of Bagira launched an angry protests, throwing projectiles at the building housing the Covid-19 treatment center located in Bagira commune of Bukavu Town.\u003c/p\u003e\u003cp\u003eAnother example can be seen in a video taken in Bukavu, in which a woman opposes an arrest by a police officer for not wearing a mask. This resistance led to a fight, simply because the police officer was not wearing a mask either. This situation shows us that the role of surveillance and enforcement of incentives by order services has faced several challenges. These include (i) the scarcity of resources to implement incentives adapted to the conditions of the population. (ii) Lack of compliance models among law enforcement officers. (iii) Accessibility constraints due to shantytown urbanization and lack of adequate traffic links. In the same context, there are informal facilities where people gather, such as markets, bars, family and cultural gatherings, which are inaccessible to the public order services. (iv) Also, from the outset, the actions of the public order services have been insufficient to ensure security in this part of the DR Congo, where there has been a crisis of insecurity for decades. Indeed, as part of the multi-sectoral response and the approach to responses integrating all sectors likely to influence the response, it emerges that the effective organization of public order services is a pillar in the implementation of mandatory response measures.\u003c/p\u003e\u003cp\u003e\u003cb\u003e4.5.5 Gaps in the organization of the healthcare system and certain legacies of the management of the Ebola epidemic in DR Congo\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe organization of the system for the detection, control and prevention of infections is a pillar of risk management for emerging infectious diseases. Firstly, rapid detection of emerging infectious diseases is essential to minimize morbidity, death and economic losses. Continuous and systematic public health surveillance of the collection, analysis, interpretation and dissemination of health data is a major pillar. Secondly, to ensure capacity for routine control functions, we need to ensure rapid laboratory development, conduct epidemiological investigations and other responses to difficult and complex public health problems. Also, the prevention of emerging infectious diseases requires the use of approved tools (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Infectious Disease Vulnerability Index (IDVI) indicates a health system's ability to monitor and control emerging diseases. DR Congo's IDVI is among the lowest in the world, compared with the system's capacity in terms of surveillance systems, laboratories, hospitals, health insurance systems, organization of emergency health response services, etc.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the case of South Kivu, there is a gap between the COVID-19 response actions communicated by the public authorities and the practical practicability of infectious disease surveillance and response. Indeed, the Governor of the province of South Kivu indicated in his March 30 communication that: \"...the province has already taken protective measures which are being reinforced to spare our population from the risk of contamination...\". Indeed, without the fundamentals of health risk management, the strategies communicated by South Kivu's public authorities were in vain.\u003c/p\u003e\u003cp\u003eMoreover, given the persistence of risk factors for the emergence of infectious diseases (close contact between human and animal environments, international transport flows, biosafety risks, etc.), there is a need to prioritize investment in in-depth infectious disease control actions (detection, control and prevention systems, as well as social and health security).\u003c/p\u003e\u003cp\u003eFurthermore, learning from the management of previous epidemics such as the 10 Ebola episodes in DR Congo has enabled the system to better organize the response to COVID-19. Nevertheless, the community's perceptions of the health system's management of previous epidemics has influenced the community's understanding of the origin of the diseases, its confidence in the management authorities and its adoption of response actions.\u003c/p\u003e\u003cp\u003eThere was a perception that the incidence of the COVID-19 pandemic was a strategy for the Congolese government to mobilize funds by establishing links with the cases of the Ebola epidemic known as \"Ebola business\", of which the country was at the same time experiencing 10 epidemic episodes. The are evidences of poor management of Ebola outbreak. 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. Therefore, the population was quick to accuse the national and provincial governments of taking advantage of the pandemic to benefit from funds from international institutions. A number of anecdotes have emerged to describe this, including \"Cop\" or \"Dili\" in Bukavu common speech to signify a non-transparent, informal affair or business. One of the Bukavu baron's lawyers tells us:\u003c/p\u003e\u003cp\u003e\"[...] I see, for example, that for Ebola we used to speak of Ebola montage, Ebola Business, Ebola Cop, and so on. When the coronavirus disease was declared in Kinshasa, it was said that there had been a handover and takeover between Ebola and Covid19 \" (extract from an interview with a lawyer, Bukavu/DRC, July 2020).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"5 Discussion","content":"\u003cp\u003e\u003cb\u003eThe social media report of the COVID-19 burden abroad and the sporadic compliance with the response measures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe main influence of the social media was the perception that the DR Congo health system would have found it difficult to respond to the COVID-19 epidemic compared to the difficulties encountered in the management of COVID-19 in the countries of the North. Despite many challenges (high level of poverty, high population density and relatively fragile health system, etc.), African countries has shown capacity in its response to the pandemic. This may be related to the continent\u0026rsquo;s experience in responding to several infectious disease outbreaks such as Ebola disease, Lassa fever and cholera (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Author way, if well structured, the communication through social networks building mainly on the risk of mortality and aiming at shocking consciences has a great potential for community engagement. According to Kharrat, in a situation of major and diverse challenges namely security, socia and economic challenge, persuasive communication based on emotions can be applied. Emotions are not limited to raise fear or anxiety in this campaign, they also serve to facilitate collective awareness of the extent of the burden and lead to an emotional involvement of citizens who will be more receptive to the arguments and prescriptions of public authorities (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Also, social networks and media have become undeniable tools of online communication and this makes them an important part of communication strategies. The strong point of social networks is interactivity. In times of crisis, many organizations have turned to social media as their main communication tool for economic and profit-making reasons. Indeed, social media allows to reach a very large audience at extremely low or no cost (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe alert du to the first cases of COVID-19 and the related communication seems to have influenced positively the adherence to the response measures at a given time. Indeed, following the first outreach on the first two cases of COVID-19 in Bukavu, prevention practices were sometimes observed. One of the most important and effective public health strategies for dealing with a pandemic such as coronavirus is to communicate proactively about what is known, what is not known, and what is being done in order to increase awareness, with the aim of saving lives and limiting negative consequences (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In addition to build trust, risk communication interventions must be linked to functional and accessible services, be transparent, be well-timed, be simple to understand, acknowledging uncertainties, address affected populations, and be disseminated through different channels, methods, and platforms (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) .\u003c/p\u003e\u003cp\u003e\u003cb\u003eInadequacies in the response coordination and socio-financial barriers for adopting barrier measures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSome weaknesses in coordination have been unfavorable to community engagement in the response. A review of reports of the national response to the COVID-19 pandemic in Africa reported that the key challenges included low public confidence in governments, inadequate adherence to infection prevention and control measures and shortages of personal protective equipment. Also the inadequate laboratory capacity, inadequate contact tracing, poor supply chain and logistics management systems, and lack of training of key personnel at national and subnational levels (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Also, in the survey setting in Bukavu City, the majority of the population lives beyond the psycho-social trauma caused by the decades of armed conflict in this region, which has led to the collapse of the population incomes. The results of Koudjom et al. has showed a positive and significant relationship between poverty and the spread of COVID-19 and suggested that more attention needs to be paid to poor populations in African countries during the pandemic. These populations are generally vulnerable, and there is a need for support programs targeting them to be put in place (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eNeed for ongoing communication and application of incentives for response adherence\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAccording to the expectation of the study population, the shortcomings of mass communication include the lack of addressing the people\u0026rsquo;s concerns, not adapted communication channels and to not communicating the impact (Side and positive) of the response measures so that people understand the importance of adhering to them. According to the CDC Field Epidemiology guide, during an outbreak, public health officials must quickly determine the communication purpose, the persons and populations most in need of information and guidance, ways to engage with news media and the public, and ways to gauge the effects of messages and materials (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Beside, during our study, interviewers have expressed rumors, misinformation, need of information related to the COVID-19 management. Relating to infodemic, health communication that starts by fostering well-being and basic human psychological needs has the potential to cut through the infodemic and promote effective and sustainable behavior change during such pandemics (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). World Health Organization recommend to achieve the infodemic management through the following 4 types of activities: listening to community concerns and questions, promoting understanding of risk and health expert advice, building resilience to misinformation and engaging and empowering communities to take positive action.\u003c/p\u003e\u003cp\u003eIn a number of cases experienced in Bukavu, the lack of continuous action by the public order services was one of the major causes of the breakdown in the application of control measures at COVID-19. Although its relevance, for public health to restrict liberties, observes Callahan, it must provide solidly based factual evidence, in other words, provide objective, scientific, hard facts to validate decisions that override autonomous decision making (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Indeed, the modelling analysis of the restrictive measures Impact on the disease spread showed that the countermeasures taken, although they are tough and restrictive, have an effective effect on reducing the rate of spread of the infection (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). A literature review research confirmed that in countries where anti-pandemic measures were rapidly and consistently in place, the spread of the virus was suppressed more rapidly and the first wave of pandemics in these countries was incomparably more benign than in countries with later responses and milder restrictive measures (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). While consequences such as fines and community service were found to be important for those who do not comply with restrictive measures, Smith et al., have reported that there ought to be no consequences in the absence of reciprocal arrangements, as in such cases individuals may be put in a position where they have no choice but to not comply with restrictive measures (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eGaps in the health preparedness capacity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe results of our survey according to the gaps in the health preperadness system is similar with other research funding\u0026rsquo;s in Africa settings. Capacity to detect and respond to epidemics and pandemics is weak in West and Central Africa and Southeast Asia, regions known to have high risk for emergence of pathogens with pandemic potential (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Health systems in Africa were inadequately prepared for the pandemic, and its impact was substantial. Responses were slow and did not match the magnitude of the problem. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). During the COVID-19 pandemic, resources to prevent COVID-19 were limited like precaution products, such as medical masks, disinfectants, alcohol-based hand rub and access to running water, especially at publicly managed facilities and facilities in rural areas (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Also, the testing capacity in African countries was very low. Most of the countries on the very low capacity need to scale up rapidly (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The COVID-19 pandemic have reduced patient flow or limited access to health services in Africa (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Jensen and McKerrow have reported during the COVID-19 pandemic significant declines for clinic attendance and hospital admissions of children age\u0026thinsp;\u0026lt;\u0026thinsp;5 years and a 47% increase in neonatal facility deaths in South Africa (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Conceptual framework of health system preparedness for EIDs comprised six health system constructs, including four hardware constructs: Surveillance, Infrastructure and medical supplies, Workforce, and Communication mechanisms; and two software constructs: Governance, and Trust (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e"},{"header":"6 Conclusion","content":"\u003cp\u003eThis works have described the different dynamics in the community compliance with COVID-19 first wave response measures, in South-Kivu, DR Congo. For organizational learning, analyse cases of non-compliance with COVID-19 measures are made. These cases are influenced mainly by the inadequacies in the response organization (coordination, risk communication, laboratory capacity, prevention, education, etc.), the socio-financial counter-motivation for adherence, the lake of continuous initiatives, the gaps in the health system structure and the negative legacies of the management of previous epidemic in DR Congo.\u003c/p\u003e\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 COVID-19 response explored should benefit from the integrate complementary strategies. This strategies could be the accompaniment of the most disadvantaged people, continuous sensitization, the application of incentives to respect the response measures. Also, to achieve the infodemic management through the following activities: listening to community concerns, promoting understanding of risk, building resilience to misinformation and empowering communities to take positive action. Capacity to detect and respond to epidemics is weak in Democratic Republic of the Congo. The initiatives to strengthen the health system preparedness require to improve capacities including: surveillance, infrastructure and medical supplies, workforce, communication mechanisms, governance, and trust.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical clearance from the Ethical Committee of the Official University of Bukavu. \u0026nbsp;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\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026rsquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.A.I. have designed the work, interpret the date and applied per review revisions. P.K.B. have collected the data and interpret the data. G.M.M, B.N.A, J.M.B. E.E.G, J.B.M., B.Z.A and I.B.E have collected the data. Y.C. have drafted the work and revisit it. All authors have reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStephen J, McKinney S, Parhi R, Kumar H, Shifau, Gray P. What have we learned about closures of education institutions during the sars outbreak of 2003 and the covid-19 pandemic? Research Papers Presented at the 8th LSME International Research Conference on \u0026lsquo;Sustainable Development and Education\u0026rsquo;. Published in 2022. 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Essential healthcare services in the face of COVID-19 prevention: experiences from a referral hospital in Ethiopia. Am J Trop Med Hyg. 2020;103:1198\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJensen C, McKerrow NH. Child health services during a COVID-19 outbreak in KwaZulu-Natal Province, South Africa., Afr Med S, Mohammed J, Oljira H, Roba L et al. KT, Containment of COVID-19 in Ethiopia and implications for tuberculosis care and research. Infect Dis Poverty. 2020;9:131.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePalagyi A, Ben J, Marais S, Abimbola SM, Topp ES. McBryde and Joel Negin. Health system preparedness for emerging infectious diseases: A synthesis of the literature. Global public health 2019, VOL. 14, NO. 12, 1847\u0026ndash;1868 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/17441692.2019.1614645\u003c/span\u003e\u003cspan address=\"10.1080/17441692.2019.1614645\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 3","content":"\u003cp\u003eTable 3 is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"health outbreak, COVID-19, restrictive measures, risk communication, incentives, compliance","lastPublishedDoi":"10.21203/rs.3.rs-6502452/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6502452/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eHealth systems in study setting were inadequately prepared for the COVID-19. Our research aimed to contribute to describe, through a socio-anthropological study, the different dynamics in the non-compliance to COVID-19 response measures, in Bukavu city, Democratic Republic of the Congo. We argue that, continuous application of the COVID-19 restrictive measures required relevant resources and competencies in a transparent management of the response pillars such as risk communication, epidemiological surveillance, prevention and control, laboratory organization, medical and psycho-social care and logistics.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA qualitative study with a socio-anthropological survey was conducted in Bukavu Town, South Kivu Province, in Democratic Republic of the Congo. An exploratory survey aiming at co-producing the study objectives with key stakeholders was conducted with 17 participants including academics, health professionals including technical agents of the COVID-19 response and community members. In- depth 86 semi-structured interviews and 5 FG each of 7 to 11 actors were organized. The interviewed actors were selected through convenience sampling and the saturation of data indicated the it size. 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. We have triangulated the opinions collected in order to verify their veracity. 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 in the data sources.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eThe study present a timeline of dynamics in the non-compliance to first wave COVID-19 measures in Bukavu, Democratic Republic of Congo. The analysis begins with the echo of the emergence of COVID-19 internationally on social media and it influence on the population's understanding. Following by, the sporadic compliance with the response measures from the experience of the first cases of COVID-19. Next, the determinants of the COVID-19 alert full down and the breakdown in the application of preventive measures are presented. These determinants are argued around (i) the inadequacies in coordination illustrated with the case of resignation of Noble Prize winner Mr. Dr. Mukwege from the COVID-19 response committee. (ii) Then, the community socio-financial disability as barrier to response adoption. (iii) Following, the lake in public order services to monitor the completion of response measures. (iv) And the gaps in the health system structure and the negative legacies of the management of the previous Ebola epidemics waves in DR Congo.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eEstablishing strategies to respond to emerging diseases is a complex challenge in fragile system contexts with inadequate health security schemes, surveillance and preparedness. As to achieve community engagement in such context, the COVID-19 response explored should benefit from an integrated complementary strategies such as the accompaniment of the most disadvantaged people, concetualized sensitization, and the application of incentives to motive the compliance.\u003c/p\u003e","manuscriptTitle":"How COVID-19 restrictive measures were not implemented in Bukavu, DR Congo: a participatory qualitative case study ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-24 13:44:33","doi":"10.21203/rs.3.rs-6502452/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"19a68b10-8dcd-4bea-a5e6-7c5f7e76f92a","owner":[],"postedDate":"July 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T10:54:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-24 13:44:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6502452","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6502452","identity":"rs-6502452","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}