Facility capacity and provider knowledge for cholera surveillance and diarrhoea case management in cholera hotspots in the Democratic Republic of Congo - a mixed-methods study

Wider healthcare-strengthening interventions are recommended in cholera hotspots and could benefit other types of diarrhoeal diseases which contribute to greater mortality than cholera. Describe facility capacity and provider knowledge for case management of diarrhoea and cholera surveillance in cholera hotspots in the Democratic Republic of Congo (DRC) among health facilities, drug shops, and traditional health practitioners. We conducted a sequential exploratory mixed-method study, using focus group discussions, facility audits, and provider knowledge questionnaires during September and October 2022 in North Kivu and Tanganyika provinces, Eastern DRC. Content analysis was used for qualitative data. Quantitative data were summarised by facility level and healthcare provider type. Audit and knowledge scores (range 0-100) were generated. Multivariable linear regression estimated association between scores and explanatory factors. Qualitative and quantitative data were triangulated during interpretation. Overall, 244 facilities and 308 providers were included. The mean audit score for health facilities was 51/100 (SD: 17). Private facilities had an -11.6 (95% CI, -16.7 to -6.6) lower adjusted mean score compared to public. Mean knowledge score was 59/100 (95% CI, 57 to 60) for health facility personnel, 46/100 (95% CI, 43 to 48) for drug shop vendors and 37/100 (95% CI, 34 to 39) for traditional health practitioners. Providers had particularly low knowledge concerning when to check for low blood sugar, use of nasogastric tubes, and dosing schedules. Knowledge about case definitions for cholera was similar between groups (range 41-58%) except for traditional health practitioners for the definition during an outbreak 15/73 (21%). Increasing awareness of cholera case definitions in this context could help improve cholera surveillance and control. Increased support and supervision, especially for private providers, could help ensure facilities are equipped to provide safe care. More nuanced aspects of case management should be emphasised in provider training.