Understanding the Broader Impacts of COVID-19 on Women and Girls in the DRC through Integrated Outbreak Analytics to Reinforce Evidence for Rapid Operational Decision-Making

in Anthropology in Action
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Simone Carter Manager, Integrated Analytics Cell, UNICEF, DRC scarter@unicef.org

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Izzy Scott Moncrieff Research Specialist, Integrated Analytics Cell, UNICEF, DRC isscott@unicef.org

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Pierre Z. Akilimali Associate Professor, University of Kinshasa, DRC pierretulanefp@ gmail.com

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Dieudonné Mwamba Kazadi General Director, General Directorate of Disease Control, Ministry of Health, DRC dieudonnemwambakazadi@gmail.com

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Karen A. Grépin Associate Professor, University of Hong Kong, Hong Kong kgrepin@hku.hk

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Abstract

Whilst men and boys account for more COVID-19 cases and deaths, the secondary impacts of the outbreak on women and girls in the Democratic Republic of the Congo are cross-cutting and far-reaching. School closures put girls at increased risk of adolescent pregnancy, sexual violence and early marriage; more women working in the informal sector have lost jobs and been affected by closures of markets and borders; and frequent restrictions on sexual and reproductive healthcare have impacted access to services for women. Lessons learnt from previous health crises can help to highlight the extent of these issues. However, a lack of sex disaggregated data around COVID-19 morbidity and mortality in the DRC means that it is impossible to fully measure and understand the impact of the outbreak on women and girls or develop and implement appropriate interventions. This article presents a meta-synthesis of existing and ongoing analyses to highlight the broader impacts of COVID-19 on women and girls in the country.

During the 2018–2020 Eastern Democratic Republic of Congo (DRC) Ebola outbreak, the Social Sciences Analytics Cell (CASS) was established as an innovative solution to provide operational, real-time evidence to better explain outbreak dynamics, including the impact of Ebola on communities and public health more generally. The CASS brought together different actors and data sources (surveillance data, data from different response pillars, health information services, population, and qualitative and quantitative community-sourced data), applying an integrated outbreak analytics (IOA) approach. The CASS is a successful case study in systematically embedding a social sciences analytics team alongside epidemiologists as a joint cell to inform outbreak response via IOA. It is also the first time the country has had such a cell systematically co-develop recommendations across studies, response actors, and locations as well as monitor and track their application over time (Carter et al. 2021; Carter et al. 2020; DeWulf et al. 2020).

The use of CASS evidence during the Ebola outbreak response resulted both UNICEF and the Ministry of Health (MoH) wanting to continue to operate the unit on a full-time basis to provide ongoing public health response support in the DRC. At the onset of the COVID-19 outbreak in March 2020, the CASS was set up within the MoH response co-ordination efforts as part of the Information Management Pillar, collaborating with epidemiologists and health information systems to systematically provide the MoH with evidence to inform decision-making. Since 2020, the CASS has also been providing similar IOA support to the MoH and national and international response actors in other public health emergencies within the DRC, including Cholera, Measles and the Plague. Applying IOA across these different public health emergencies, we have observed the consistent lack of gendered analyses used to understand outbreak dynamics and their impacts on communities. Furthermore, we have observed that gendered dimensions often highlight structural and social inequalities, making the co-development of real-time action to address them more challenging.

We have set up and managed the CASS (Carter); overseen the ongoing operational studies, including the presentation of results and co-development of recommendations for c Cholera, the Plague and COVID-19 (Scott Moncrieff); overseen the collaboration between the CASS and the MoH for evidence-sharing and use (Akilimali, Mwamba Kazadi); and contributed to greater use of IOA through the analysis of routine health information systems (Grépin). All of us have worked together during workshops and report development to reinforce the use of evidence on the gendered impacts of COVID-19.

The IOA approach focusses on bringing together multiple data sources and methodologies for a more holistic and comprehensive understanding of outbreaks beyond transmission. In the context of COVID-19, while estimating the true number of cases in the DRC is limited by testing capacity (Wells et al. 2020), the broader impacts of the pandemic have been heavily felt by communities and documented by the academic and operational partners working in the DRC. Evidence from previous large-scale outbreaks (e.g. the 2014–2016 West Africa Ebola outbreak as well as the 2018–2020 Eastern DRC Ebola outbreak) have highlighted the limited work that has been done to measure, evaluate and mitigate the negative impacts of outbreaks on communities and community health, notably those faced by women and girls (Ripoll et al. 2018). To bring attention to this lacuna, in June 2020 the CASS, together with partners from the WHO, SSHAP, GOARN, LSTHM, ITM, Anthrologica and Harvard, developed guidance briefs to better inform COVID-19 outbreak response in humanitarian contexts, specifically highlighting the critical importance of ensuring a gendered response, which includes collecting sex and gender outbreak-related data (CASS 2020). The CASS has since focussed its efforts on ensuring that it collects, analyses, presents and reinforces the use of evidence which highlights the impacts of COVID-19 on women and girls in the DRC.

This work is situated in a more recent history of anthropological and social science involvement in epidemic response, which escalated during the 2014–2016 West Africa Ebola epidemic (Abramowitz 2017). The typical epidemic containment model of isolation and quarantine, paired with safe burials, was often implemented without community engagement or understanding of the cultural context (Pellecchia et al. 2015). Furthermore, the lack of contextual and gendered analyses of the response failed to highlight and address the larger burden of Ebola on women and girls, including increased sexual violence, underage pregnancy, unpaid care work and maternal death (Harman 2016; Jones et al. 2016; Strong and Schwartz 2018). Anthropological work brought nuance to and challenged this paradigm of ‘one-size-fits-all’ epidemic response (Wilkinson et al. 2017). Anthropologists, largely through the Ebola Response Anthropology Platform, drew attention to the pitfalls of context-blind intervention that is reliant on a high level of public uptake (Abramowitz 2017; Fairhead 2016).

Building on these successes, key actors have worked towards the integration of social science and anthropological insights into COVID-19 response. Alex Tasker and Lucy Irvine in this issue, for example, reflect on the lack of familiarity with qualitative data in the UK government's COVID-19 response and the opportunities for the integration of social science. Once social science insights are recognised, there is a vital opportunity to improve the attention paid to local vulnerabilities, including gendered vulnerabilities. Other social scientists have called for critical attention to paid to the gendered determinants and impacts of health emergencies (Harman 2021) and for the sex-disaggregation of COVID-19 data (Wenham et al. 2020). The Gender and COVID-19 Working Group is one interdisciplinary space that works to ‘better analyse and address the gendered impacts of COVID-19’.1

The results presented in this article do not represent all available data sources; however, they include CASS qualitative longitudinal data (collected from groups of men, women, young women and healthcare workers monthly since May 2020), surveys available from multiple academic and operational actors, non-governmental organisation (NGO) programme data and programme reports, as well as the MoH data made available via the Digital Health Information System (DHIS2). Each study or data source has been analysed using its own methodology, and the programme data and study results were collated by CASS teams and analysed for recurrent themes. Data on the impacts of COVID-19 on women and girls was coded with regard to the following impacts: (1) socio-economic; (2) food security; (3) health services access and use; (4) sexual and reproductive services and needs; (5) safety and protection (including sexual and gender-based violence, SGBV); and (6) education. The meta-syntheses were then shared back with the original owners of the programme data or study results to validate the interpretations.

This process has been recurrent since June 2020, as the CASS continues to collect and collate data from these sources to better understand COVID-19 impacts and how this may change over time. The CASS teams continue to develop presentations and reports to share pertinent findings highlighting real-time problems which require immediate action. Through quarterly workshops, the CASS further brings together actors, including the donor community, to validate the results of integrated analytics and to reinforce the use of data for COVID-19 programming.

The effects of COVID-19, and its response interventions on women and girls, presented in this article are the result of a meta-synthesis of the data which CASS teams have been able to collect, collate and verify in order to inform real-time decision-making and advocate greater investment in the needs of women and girls affected by the pandemic. Where limited quality data exists, regardless of sex disaggregation, the unique IOA approach is vital to ensure that the full spectrum of real-time problems are captured, creating space for the co-development of actions and use of evidence.

Income and Food Insecurity

In the DRC women and girls often face socio-economic disadvantages as a result of early and underage marriage, early exit from education and child labour. Women ages 15-49 are less likely to read and write than men and only half as likely to have information to media (radio, television or newspapers). Women also spend more time collecting water and managing unpaid care work at home (UNICEF 2019). The lack of education and literacy, limited access to information about employment opportunities, and the limited available work hours outside the home due to care responsibilities leave women with less employment options and make them more likely to accept high-risk, low-paid and informal work.

Women's employment in the DRC is concentrated in agriculture and small businesses in the informal trade sector (where they occupy 64 per cent of jobs) (IMF 2015; JICA 2017), mainly in the sale of food and low-value perishable products. This sector is generally unregulated (Cano 2019), heavily taxed and does not benefit from social security or other government benefits. The border and market closures implemented as part of the response to COVID-19 resulted in limited business opportunities for women, many of whom lost access to their workplaces, customers and products for sale. Most women interviewed during CASS research in Goma and Kinshasa in October 2020 said they had not yet returned to work, although confinement restrictions had been lifted in June. In comparison, most of the men interviewed as part of the same study in Kinshasa had at least partially returned to work.

In August 2020, 70 per cent of households included in a Partnership for Evidence-Based Response to COVID-19 (PERC) survey across the DRC reported lower incomes compared to the same period in 2019 (n = 1,351). ELAN household surveys across the DRC conducted between August and September 2020 found that 87 per cent of women compared to 76 per cent of men reported a decrease in their household income (n = 2,200). In a follow-up survey conducted in October 2020, 79 per cent of households reported having experienced a significant increase in food prices and 59 per cent of female respondents compared to 38 per cent of male respondents reported that they were required to receive hand-outs of food or household items from the government or other organisations since COVID-19 because of reduced access to products and services (n = 2,200) (ELAN 2021). In further ELAN household surveys conducted in February 2021, 50 per cent of women reported increased costs, and 54 per cent reported reductions in income since the beginning of the outbreak, highlighting the protracted, longer-term impact of the outbreak on household finances. This problem does not appear to have reduced over time. Some 87 per cent of women in ELAN surveys in February 2021 highlighted increased food prices as the central reason for reduced disposable income, compared to 79 per cent in the October 2020 iteration of the survey. A survey conducted through UNDP and Harvard Humanitarian Initiative in November 2020 in Bunia, Bukavu and Goma found that 90 per cent of women compared to 80 per cent of men reported a worsening financial situation since COVID-19 (n = 2,327) (UNDP 2020).

CASS data from October 2020 found women in Goma reporting being forced to reduce the size and frequency of the meals they eat each day to be able to adequately feed their children. Some 55 per cent of women in the October ELAN household survey also reported decreasing household food and water consumption (n = 2,200). A study by the National Institute of Statistics (INS) and the World Bank from June and July 2020 in Kinshasa reported that 87.8 per cent of households were worried about not having enough food and that 80.4 per cent had reported reducing the number of meals per day (n = 1,596) (INS 2020). The following comment brings home this reality in more human terms:

I go all day without eating when I have a baby to breastfeed … even the neighbours who could help didn't have any food … COVID-19 is a disease that has come to kill us in whilst we are alive. Instead of suffering like this, it is better that the corona kills us directly. (Mother, Goma October 2020)

Healthcare Services Access and Use

The MoH's DHIS2 data on health services use indicated a sharp decline in the number of visits by men and women in Kinshasa at the beginning of the outbreak. This correlated with the start of a three-month period of confinement in the Gombe area of the city, suggesting that the main reason for delays and reduced healthcare demand and service use was the restriction of movement, preventing people from physically accessing services. The decline in use was 90 per cent amongst women compared to 75 per cent amongst men. Qualitative CASS evidence highlighted that difficulties in accessing transport during the period of confinement, fear of being wrongly diagnosed as a case of COVID-19, fear of indefinite forced quarantine and lack of financial means were the main barriers for women to seeking care. Despite a partial recovery in the number of visitors which coincided with the end of the confinement period and the resumption of activities in Gombe, the monthly average number of outpatient visits recorded in March 2021 was still considerably lower than the figures reported before confinement (Figure 1). CASS analysis suggests that the reduction in outpatient visits seen from August onwards was mainly due to increasing financial pressure and a reorientation of household priorities, which were impacts more frequently cited amongst women.

Figure 1.
Figure 1.

DHIS2 healthcare services use in Gombe, Kinshasa DRC

Citation: Anthropology in Action 29, 1; 10.3167/aia.2022.290106

Qualitative data from Goma found that women reported having a limited understanding of the measures that would be taken if a person tested positive for COVID-19. Most women believed that this would involve being transferred to a separate treatment centre and being detained for several weeks. Due to this fear, they would wait longer before seeking care if they perceived their symptoms to be like those of COVID-19, namely running a fever or getting a cough.

Since August 2020, mentions of COVID-19 and any associated risks became less frequent each month in CASS data, suggesting that fear of the disease or associated factors was a less important consideration, or no longer a considerable barrier to accessing care. Increasingly, the data identified money as the main factor limiting women's access to care and use of services, as the financial impact of the protracted outbreak and response forced women to change their priorities. Most women interviewed in Goma and Kinshasa in December 2020 said that food and the ability to feed their children were their main priorities and that they had concerns for the coming months about the accessibility of food. None of the women said that they had set money aside for healthcare, preferring to deal with health problems and find a way to pay for them if and as they arose.

Sexual and Reproductive Health

During qualitative interviews conducted by the CASS in Goma and Kinshasa in September and October 2020, healthcare workers and community members said that they had observed more pregnant women and girls in their neighbourhoods, churches and health facilities since the arrival of COVID-19. This finding was echoed in interviews with healthcare providers at Marie-Stopes-International-supported mobile clinics in Kinshasa and in Tshopo district, where staff reported an increase in the number of pregnant women and girls coming to their clinics for consultations and observed in the surrounding neighbourhood (CASS 2021a). This trend continues to be reported across the country in 2021. Confinement measures, job losses and restrictions on movement were cited as the main explanations for the increase in pregnancies, as men and women spent more time together at home. In addition, school closures removed the structured environment that generally ensured the safety of girls, as well as regular supervision by teachers, which many parents were not able to replicate. This increased the risk of teenage pregnancy and removed opportunities to provide sexual health education that could normally be provided in schools. Testimonies of teachers, parents and students from CASS research in Masisi and Goma in December highlighted numerous examples of girls who became pregnant during the initial school closure period, resulting in many who did not return to school once their pregnancy began to show. During interviews in April 2021 in rural areas of Ituri province (CASS 2021b), several primary and secondary school teachers reported instances where girls, who had initially returned to school once they opened in October 2020, dropped out in the following months once they became visibly pregnant:

We had noticed that for girls the impact was greater than for boys, given [that we saw] more than six pregnancies in one school year. It's complicated because boys can get a girl pregnant and still study, but girls, once they get pregnant, that's the end for them.

(Teacher, Masisi, December 2020)

In a study contacted by the NGO Save the Children in October 2020, 72 per cent of respondents (parents and children [11–17 years]) reported an increase in teenage pregnancies in their neighbourhoods (n = 400) ever since the schools were forced to close. GHOVODI (Groupe des Hommes Voués au Développement), an NGO operating in North and South Kivu, reported that 73 girls from the 20 secondary schools they support in Goma and Nyiragongo did not return to school after the initial reopening due to pregnancy (CASS 2021a).

Health facilities were required to adhere to government COVID-19 prevention and control policies regarding gatherings of people. This impacted the provision of antenatal care (ANC), as group health promotion activities were restricted, and in some cases cut completely. Interviews with healthcare workers and women in Kinshasa and Goma in July 2020 highlighted that the restructuring of ANC sessions to reduce group sizes (in accordance with COVID-19 response measures) and the suspension of group health promotion activities also impacted women's participation. In addition to offering specific information and promoting best practices in pre- and post-natal care for mothers, the data suggests that, compared to individual sessions, group ANC sessions lead to higher rates of institutional delivery – an important factor in reducing maternal and neonatal mortality (Greiner et al. 2019).

Women in CASS qualitative studies in August frequently cited this group element of ANC as the most useful, and often the sole reason that they would attend, since they could receive similar advice and support to what they received from friends or family members who had previously given birth and who had one-on-one consultations with a medical professional.

Health services usage data from March to May 2020 shows a reduction in the use of family-planning services in Kinshasa. Qualitative data suggests that many women did not consider obtaining contraception as an urgent need during a period when there were concerns about visiting healthcare facilities, and that this has to do with the risk of COVID-19 infection and enforced quarantine. However, from May 2020 onwards DHIS2 data showed an increase in the use of family-planning services. Qualitative data suggests that the main factor motivating married women's demand for contraception was a growing concern about the long-term financial implications of having an additional child at a time when finances are strained. Healthcare workers reported an increase in the number of adolescent girls seeking access to contraceptives, and generally believed that this reflected increased sexual activity – a consequence of school closures. Data from CARE International in North Kivu also showed a 74 per cent increase in the number of adolescent girls (< 19 years) visiting their supported health facilities for family-planning services between March and October 2020 (new users). Healthcare workers from Marie Stopes International (MSI) clinics in Kinshasa highlighted the difficulties in engaging adolescent girls with their services since the beginning of the COVID-19 outbreak. Staff reported observing older women criticising young women and adolescent girls for needing to use family-planning and reproductive health serv = ices and for not abstaining from premarital sex. Other staff consulted with girls who feared that other women they knew might report to their parents that they were visiting the clinic:

Young girls are sometimes frustrated when they meet women who know them, or who are the same age as their mothers and who talk badly to them because they already use the planning service. (Healthcare worker, Kinshasa, October 2020)

The Performance Monitoring for Action (PMA) longitudinal population study ongoing in Kinshasa found that, in June 2021, no significant changes had been identified in contraception use overall; however, it did report that an increased need for contraception was found amongst nulliparous women (Wood et al. 2021a), further reinforcing the CASS qualitative data in which women reported wanting to delay pregnancy as a result of the socio-economic impacts of the pandemic. The PMA study also found that in Kinshasa nearly 70 per cent of women reported complete COVID income loss related to COVID-19. Previous PMA results have found that women with a higher contraceptive autonomy were more likely to use contraception, indicating that the serious socio-economic impact of the pandemic must be monitored closely, given its potential impact on unintended pregnancy (Wood et al. 2021b).

The socio-economic impacts of COVID-19 have influenced maternal, sexual and reproductive health (SRH) decision-making for women and girls in the DRC. MSI, which provides free SRH services in Kinshasa and Tshopo province through mobile clinics, targeting women in remote and disadvantaged areas, shared data indicating a 350 per cent increase in the number of visits between April and July 2020 (during the national state of emergency) (from 1,643 to 5,819). Between March and October 2020, CARE International also reported a 44 per cent increase in the number of women and girls visiting the health facilities they support for family-planning services. Qualitative data suggests that the decision to seek contraceptives during COVID-19 could be a trade-off between the short-term costs and the longer-term costs of raising a child. Interviews with MSI health staff highlighted an increase in the number of women consulting for contraceptive methods accompanied by their husbands, and some also cited a general shift in women's preferences from short-term (three months) to longer-term methods of contraception (3–10 years) such as IUDs and implants.

CASS interviews with healthcare workers and communities in Kinshasa and Goma indicated a perceived increase in the number of pregnant women and girls who, without other options, sought clandestine abortions or drugs from pharmacies to perform abortions themselves. Some respondents hypothesised that health personnel perform clandestine abortions to supplement their income, the number of which has decreased significantly since the start of the COVID-19 outbreak, reflecting a decline in the number of patients. It is difficult to quantify the impact that COVID-19 response measures may have had so far on the frequency of abortions in a context where this act is illegal under most circumstances, and therefore poorly documented. Pharmacy inventory reports showing changes in the sale of drugs known to induce foetal abortion could be used as an indicator, as could attendance at health facilities by women seeking post-abortion care. For example, staff at MSI mobile clinics in Kinshasa reported in October 2020 that more women and adolescents were using emergency contraception and post-abortion care services than in April and May. However, these indicators alone are insufficient.

Safety, Security and the Syndemic of COVID-19 and SGBV

Multiple reports and studies across the country have highlighted the detrimental impact of school closures on girls in the DRC, despite the fact that schools reopened in February 2021. A study conducted in October 2020 by REACH examined changes in school attendance through key informant interviews at the beginning of the new school year in South Kivu and Tanganyika provinces, after the seven-month closure imposed as part of the national COVID-19 response strategy. More than two-thirds (67 per cent) of teachers interviewed in South Kivu reported a reduction in school attendance (n = 99), compared to 39 per cent in Tanganyika (n = 76). In South Kivu, amongst secondary school teachers, 35 per cent said that the number of girls aged 12–17 attending school had decreased, compared to 13 per cent who said that the number of boys aged 12–17 attending school was lower than it was before the closure of schools. The main reason provided by teachers for adolescent girls leaving school was that they were married during the school closure period. Adolescents who do not have the structure and safe space provided by school are more likely to engage in sexual activities, including transactional sex, which increases the risk of violence, pregnancy and the transmission of sexually transmitted infections. In the DRC, there is no law or policy specifically protecting the continued education of pregnant girls and teenage mothers. As a result, any girl who became pregnant during the period when schools were closed (who was unable to access emergency contraception or abortion services) risked being unable to return to school:

For the last five months, the children have been at home doing nothing … I have personally seen three young girls in my neighbourhood become pregnant … they did not go back to school. (Young woman, Goma, October 2020)

A helpline operated by the Forum of Women Citizens Committed to Governance, Democracy and Development in Kinshasa offering support to victims of domestic violence recorded 20 times more calls from women than men between April and July (during the national state of emergency) (FOFECEGDD 2020). Some 78 per cent of calls concerned cases of domestic and sexual violence against children under 14. The humanitarian NGO Médecins du Monde reported double the number of cases of sexual or gender-based violence (SGBV) received in its health centres in Kinshasa between April and June 2020 (MDM 2020). Such examples demonstrate the exacerbating impact that COVID-19 has had on the broader public health emergency of SGBV, leaving women and girls in a syndemic crisis (Stark et al. 2020).

DHIS2 data from North Kivu province shows a sharp increase in new cases of SGBV reported since July 2020, with a particularly large increase in Goma (Figure 2). Acknowledging that men can also be at risk of sexual and gender-based violence, the vast majority of cases are perpetrated by men towards women. The DHIS2 data highlights that less than 50 per cent of survivors of SGBV were presenting at health facilities within 72 hours of an incident occurring. This can have considerable implications for female survivors who may have been exposed to HIV infection, as post-exposure prophylaxis (PEP) is rendered ineffective outside of a 72-hour timeframe (in addition to being the window during which unwanted pregnancy can be easily prevented).

Figure 2.
Figure 2.

DHIS2 data on sexual violence in Goma, DRC, from January 2018 to November 2020

Citation: Anthropology in Action 29, 1; 10.3167/aia.2022.290106

Ongoing CASS research exploring the impacts of school closures on children and youth across the DRC (December 2020–) has highlighted an increase in frequency of girls exchanging sex for money since the beginning of the COVID-19 outbreak. In December 2020, teachers in Masisi and Goma provided several examples of adolescent girls who were encouraged by their parents to have sex for money to support their families. These situations were perceived to considerably increase the risk of SGBV, pregnancy and HIV/STI transmission for girls. Night markets frequented by children and adolescents whilst schools were closed were cited by parents in eastern Ituri during CASS focus group discussions as environments where girls would specifically go to meet men and exchange sex for money, or items for sale. Several further reported cases of sexual violence towards girls at these markets, highlighting a lack of supervision from parents, alcohol and limited lighting as contributing factors (CASS 2021a, 2021b).

Increases in cases of early marriage were further cited as a major impact of the school closures on adolescent girls. In CASS focus group discussions conducted with men and women in rural Ituri and Tanganyika in April and May 2021, respectively, the typical age of marriage was frequently cited as 12 or 13 years. All participants noted an increase in the number of girls under 18 marrying, primarily following a pregnancy, during the periods when schools were closed. Parents in Ituri considered the main reason for this to be increased exposure to alcohol and drugs (during night markets coupled with the decreased motivation or willingness of children and adolescents to study or respect their parents). Interviews in Tanganyika highlighted a lack of family income as a driver for girls to marry early. Some parents suggested that the dowries received for daughters were an incentive for families to keep daughters out of school once they reopened. Parents further reported adolescent girls searching for their own sources of income being attracted by the possibility of marriage to men who may be able to provide for them in a way that their families were unable to do (CASS 2021c).

Compounding, Intersectoral Effects

COVID-19 has had a compounding impact on the lives of women and girls in the DRC. Lost income, increased food prices, barriers to safe access to healthcare services, school closures and restricted movements of people and produce have left women increasingly vulnerable in an environment where the divide between men and women is already starkly transparent. This has put women and girls at increased risk of SGBV from a reliance on the exchange of sex for money, in addition to health complications and risks associated with being limited to accessing healthcare through cheaper, clandestine means. Reduced household income was reported as a main factor limiting a return to school for children and adolescents. Several men and women interviewed during CASS research in rural Tanganyika reported that, with the reopening of the schools, they only had funds to pay for some children to return, and that therefore sons were prioritised. Sons were considered to ‘have more of a future’ and be a better guarantee for old age for parents. Furthermore, many women during the closure period had relied on school-aged daughters as carers for younger siblings whilst they were working and did not feel able to lose this as a resource. This subsequent lack of education for girls may impact future opportunities in the workplace, and likely perpetuate a cycle of poverty and poor health outcomes for women (Browne and Barrett 1991).

Using Data for Action

The IOA approach provides a holistic view of disease and behavioural dynamics where quality data from individual sources may be lacking, increasing the reliability and robustness of evidence to influence decision-making. Since 2018, a model for the co-development of recommendations was agreed upon based on workshops held with MoH actors. The approach ensures that evidence is shared across multiple levels and actors and adapted to various audiences. This includes presenting to local health actors and community associations as well as national and international NGOs and district or provincial health authorities and the United Nations. Results may be presented during small meetings, larger presentations, or workshops. The aim to co-develop recommendations included identifying who would be responsible for them and how the recommendations would be put into action and followed up with over time. Indicators to measure their application were also agreed upon.

As the CASS sits within the MoH COVID-19 response co-ordination efforts as part of the Information Management Pillar, the CASS is able to systematically share results and inform response leadership. Results presented in this article followed the co-development process across multiple presentations and forums. Presentations included local civil society groups, national and international NGOs, the United Nations and government, and the recommendations co-developed included changes to programme activities and strategy development and advocacy for policy changes and for greater investment from donors to support access to sexual and reproductive healthcare, household food security and education for children.

Some specific examples of the co-development of actions and use of evidence included the following recommendations:

1. Reopening of schools in the DRC: the CASS first compiled evidence on the impacts of school closures in Eastern DRC in November 2020. Additional data collection on the impacts of school closures and the non-return of girls was collected by the NGO REACH (2020) through key informant interviews. U-Report, a digital engagement platform, further collected data from youth across the country. In addition to the country-specific data, the CASS compiled evidence on risks of school closures from previous outbreaks (e.g. West Africa Ebola outbreak) and from reports and publications regarding transmission of COVID-19 in schools. This data compilation was shared with the MoH COVID-19 secretariat and response leadership weekly, in order to advocate policy change, demonstrating through IOA the detrimental impact of school closures across the country. As the CASS sat within the MoH-led COVID-19 response co-ordination efforts, this data contributed to decision-making for school reopening in February 2021

2. Reinforce return to school amongst pregnant girls in Eastern DRC: Following the first data collection in November 2020, the CASS team worked with different local actors to use evidence to support the safe return of girls who had become pregnant during school closures. Meetings were held with the heads of general services of the sub-division of private and public schools to identify the parents and families of girls who had become pregnant during school closures. Follow-up engagement and dialogue activities were organised to reinforce the importance of education for girls, even post-childbirth and an Official Note was published by the government asking school officials to reintegrate girls who had dropped out of school because of pregnancy.

3. School programmes on sexual and reproductive health in Goma: the NGO Humanitarian Organization for Lasting Development (HOLD) organised awareness-raising sessions on sexual and reproductive health in 15 schools in the city of Goma. Following the presentation of findings from the CASS, and the identification of areas most affected, they set up clubs for adolescents to discuss the issue with peer educators. These interventions were based on both the school closures study and the impacts of COVID-19 on women and girls and were aimed to reinforce adolescents’ knowledge of and education on sexual and reproductive health, aiming to prevent early pregnancy.

4. RENADEF (National Network of NGOs for Women's Development) project for the economic empowerment of women in rural areas: following the presentation of the results of the COVID-19 impacts on women and girls analysis on 21 January 2021, this project was developed to strengthen women's involvement in agriculture and livestock raising, so that they would be less dependent on their husbands’ resources (especially in times of economic crisis). This project had already been identified before the CASS presentation; however, the CASS’ integrated analyses reinforced the foundation of their work in evidence (e.g. the fact that women are more vulnerable to the economic crisis due to the preponderance of informal work) so that RENADEF could ask for greater funding for the response.

5. Coulibaly Centre and family planning: the association works with students on family planning and, following the presentations of CASS results, identified the need to involve men more and to organise community awareness-raising activities with men and young men on the theme of family planning. As a result of this work, of the 5,479 people reached door-to-door in four sites (November and December 2020), 3,466 were men, and amongst these men were scientists from the University of Kinshasa, motorbike drivers, and adolescents. This is the first time that the association has really involved men in the targets of these awareness-raising activities, recognising that men may hold more decision-making power and influence for women's access to family planning, notably following the negative socio-economic impacts of crises on women.

Discussion: Challenges in Data Collection and Use

Data available in the DRC shows that intervention measures against COVID-19 have disproportionately impacted women and girls. It is critical therefore to recognise the syndemic nature of COVID-19, as it exacerbates vulnerabilities and comorbidities. The IOA approach taken by the CASS and partners demonstrates, through multiple data sources and methodologies, the continued and compounding negative impacts of the pandemic on the health and safety of women and girls in the DRC. The existing body of evidence provide a compelling case for improved action to better understand and address the impacts on and needs of women and girls affected by COVID-19 in the DRC. Our work contributes to this literature (Harman 2021; Wenham et al. 2020) and underscores the vital role of integrating social science into epidemic response. We demonstrate both the feasibility and the necessity of integrating such social science insights notably in regards to understanding the gendered dimensions of outbreaks and their impacts on women and girls.

To date however, the narratives of women and girls, even when reinforced with DHIS2 and representative household data, seem unable to gain the same attention or financial investment as those of COVID-19. One challenge remains in the availability of actionable sex-and age-disaggregated data. Although the CASS and many partners do collect data on the specific impacts of COVID-19 on girls and women, much of the data on the impacts of the outbreak both in the DRC and globally continues to be analysed and presented without sex disaggregation (Heidari et al. 2020). For example, data on food security is rarely separated by sex, making it difficult to fully understand the extent of the problem and how growing food insecurity cultivated by the response to COVID-19 could affect women and girls (Lieberman 2021). This critical sex and gender data gap means that overall impact is impossible to measure, and that specific interventions to mitigate and address these impacts cannot be developed and implemented. Failing to collect or present sex and gendered data will limit the operational and actionable use of data and result in a failure to act on the needs of women and girls (Perez 2019).

Applying an IOA lens in outbreak response can provide response actors with critical information on the gendered dimensions of an outbreak, including the impacts of outbreak response measures on the long-term health and security of women and girls. IOA presents evidence beyond the direct disease impacts (caseload) and, for COVID-19 in the DRC it has provided critical evidence on impacts on healthcare services use, broader negative health outcomes (increased pregnancy, decreased prenatal care), increased power imbalances and socio-economic disparity. The evidence provided by IOA, however, is insufficient and requires sufficient investment (financial, strategic) as means to be put in action.

When data is available, it should be acted upon. However, in humanitarian contexts, such as that of the pandemic in the DRC, many pre-determined programmes and funding streams may make it challenging to adapt response strategies in real time based on qualitative, mixed methods and IOA evidence. Considering the long history and evidence of the impacts of outbreaks on women and girls (WANEP 2020), proposing funding streams which are specifically dedicated to the needs of women and girls (e.g. 50 per cent of funds allocated for water, sanitation and hygiene interventions must be demonstrated to prioritise women and girls) may be one opportunity. Additionally, creating flexible funds, which are made available to support programme adaptation based on evidence of the impacts of COVID-19 on women and girls, may be another opportunity to reinforce evidence-based action.

The setting up of IOA in the CASS within the MoH and the latter's operation as a service to response actors can facilitate the use of evidence, as donors and decision-makers are engaged in the process from the onset. This has been demonstrated by 51 recommendations which were co-developed between 2020 and 2021 to address the impacts of COVID-19 following the presentation of study findings. As of the end of 2021, 48 of the 51 (94 per cent) of the recommendations had been put into action.

Acknowledgements

The CASS work and reports are the result of multiple actors coming together to share data and evidence with the aim of obtaining a more holistic understanding of the impacts of COVID-19 on women and girls. The CASS work is supported by ethical clearance from the Institut National de Recherche Biomédicale (INRB), and the CASS been able to conduct such operational work thanks to Professor Steve Ahuka (INRB) and Professor Pierre Akilimali (Kinshasa School of Public Health). The analysed DHIS2 data presented in this article has been provided with support from the DRC MoH, Gregoire Lurton (Bluesquare), Dr. Joseph Kasongo Wa Kasongo (MoH) and Shuo Feng (University of Hong Kong).

The CASS is made up of local research teams from Kinshasa, Goma, Butembo, Beni, Bukavu and Mbandaka. It was with their engagement, connection to communities and work that much of this data was able to be collected, and it was with their networks that the data was shared back to the communities. We would like to extend our appreciation to those who contributed not only to data-sharing, but to the review of the original operational brief as well as to the workshops aimed to give attention to and address the impacts of COVID-19 on communities. Notably, we would like to thank Bas Zuidberg (ELAN); Neha Singh (LSHTM); Matthea Roemer, Pascale Barnich, Josee Bahizi and Jules Ibonga (Marie Stopes International); Sara Pizzacaro (Médecins du Monde); Giuliana Serra and Katya Marino (UNICEF); Patrick Vinck and Phuong Pham (Harvard Humanitarian Initiative); Bene Kimathe (GHOVODI); and Simon Benezero and his team at Youth Alliance for Reproductive Health in Goma.

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Contributor Notes

Simone Carter is the Manager of the Integrated Analytics Cell in the DRC and the Lead on Integrated Outbreak Analytics for UNICEF Public Health Emergencies. She has a Master's of Science in epidemiology from the University of British Columbia. E-mail: scarter@unicef.org

Izzy Scott Moncrieff is a Research Specialist with UNICEF's Integrated Analytics Cell in the DRC. She supports field research teams with operational analytics for different public health emergencies across the country. E-mail: isscott@unicef.org

Pierre Z. Akilimali is an Associate Professor of Medicine and Public Health at the Kinshasa School of Medicine and the Kinshasa School of Public Health, University of Kinshasa, and Principal Investigator of the PMA study in the DRC. E-mail: pierretulanefp@gmail.com

Dieudonné Mwamba Kazadi is a General Director at the General Directorate of Disease Control, MoH; PhD Candidate at University of Montreal and Assistant at the Kinshasa School of Public Health, University of Kinshasa. E-mail: dieudonnemwambakazadi@gmail.com.

Karen A. Grépin is an Associate Professor at the University of Hong Kong's School of Public Health. She has a PhD in health policy (economics) from Harvard University. E-mail: kgrepin@hku.hk

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Anthropology in Action

Journal for Applied Anthropology in Policy and Practice

  • Figure 1.

    DHIS2 healthcare services use in Gombe, Kinshasa DRC

  • Figure 2.

    DHIS2 data on sexual violence in Goma, DRC, from January 2018 to November 2020

  • Abramowitz, S. (2017), ‘Epidemics (Especially Ebola)’, Annual Review of Anthropology 46: 421445, doi:10.1146/annurev-anthro-102116-041616.

    • Search Google Scholar
    • Export Citation
  • Browne, A. and H. Barrett (1991), ‘Female Education in Sub-Saharan Africa: The Key to Development?’, Comparative Education 27, no. 3: 275285, http://www.jstor.org/stable/3099297.

    • Search Google Scholar
    • Export Citation
  • Cano, M. (2019), Literature Review of Gender and Power Analyses in the Provinces of North and South Kivu Kivu, DRC, March, CARE, http://www.careevaluations.org/wp-content/uploads/Gender-analysis-North-and-South-Kivu_March-2019.pdf.

    • Search Google Scholar
    • Export Citation
  • Carter S. E., S. Ahuka-Mundeke, J. Pfaffmann Zambruni, C. Navarro Colorado, E. van Kleef, P. Lissouba, … and N. Gobat (2021), ‘How to Improve Outbreak Response: A Case Study of Integrated Outbreak Analytics from Ebola in Eastern Democratic Republic of the Congo’, BMJ Global Health 6, no. 8: e006736, doi:10.1136/bmjgh-2021-006736.

    • Search Google Scholar
    • Export Citation
  • Carter S. E., N. Gobat, J. Pfaffmann Zambruni, J. Bedford, E. van Kleef, T. Jombart, … and S. Ahuka-Mundeke (2020), ‘What Questions We Should Be Asking about COVID-19 in Humanitarian Settings: Perspectives from the Social Sciences Analysis Cell in the Democratic Republic of the Congo’, BMJ Global Health 5: e003607, doi:10.1136/bmjgh-2020-003607.

    • Search Google Scholar
    • Export Citation
  • CASS (Social Sciences Analytics Cell) (2020), Social Science Support for COVID-19: Gender Inclusiveness in COVID-19 Response Operations, May, UNICEF, https://www.unicef.org/drcongo/en/reports/social-science-support-covid-19-gender-inclusiveness-covid-19-response-operations.

    • Search Google Scholar
    • Export Citation
  • CASS (Social Sciences Analytics Cell) (2021a), COVID-19 School Closures in the DRC: Impact on the Health, Protection and Education of Children and Youth, May, https://www.socialscienceinaction.org/resources/covid-19-school-closures-in-the-drc-impact-on-the-health-protection-and-education-of-children-and-youth/.

    • Search Google Scholar
    • Export Citation
  • CASS (Social Sciences Analytics Cell) (2021b), ‘Understanding the Risk Factors for Transmission and Behavioral Dynamics around the Suspected Plague Outbreak in Ituri Province’, unpublished paper.

    • Search Google Scholar
    • Export Citation
  • CASS (Social Sciences Analytics Cell) (2021c), ‘Exploring the Gender Determinants of Malnutrition in Children in Kabalo, Tanganyika’, unpublished paper.

    • Search Google Scholar
    • Export Citation
  • Dewulf, A.-L., A. Mushagalusa Ciza, L. Irenge, E. Kandate and V. Barbelet (2020), Collective Approaches to Risk Communication and Community Engagement in the Ebola Response in North Kivu, Democratic Republic of Congo, October, Oversees Development Institute, https://odi.org/en/publications/collective-approaches-to-risk-communication-and-community-engagement-in-the-ebola-response-in-north-kivu-democratic-republic-of-congo/.

    • Search Google Scholar
    • Export Citation
  • ELAN (2021), ‘Socio-Economic Impacts of the COVID-19 Crisis on Households in the Democratic Republic of Congo’, https://www.elanrdc.com/households-en (accessed 1 January 2022).

    • Search Google Scholar
    • Export Citation
  • Fairhead, J. (2016), ‘Understanding Social Resistance to the Ebola Response in the Forest Region of the Republic of Guinea: An Anthropological Perspective’, African Studies Review 59, no. 3: 731, doi:10.1017/asr.2016.87.

    • Search Google Scholar
    • Export Citation
  • FOFECEGDD (Forum of Women Citizens Committed to Governance, Democracy and Development) (2020), ‘Report on the Cases of Domestic Violence Reported in the City of Kinshasa from March to December 2020’, paper presented during a press conference, Kinshasa, 10 December.

    • Search Google Scholar
    • Export Citation
  • Greiner, L., S. Suhowatsky, M. M. Kabue, L. M. Noguchi, D. Mohan, S. R. Karnad and J. M. Smith (2019), ‘Impact of Group Antenatal Care (G-ANC) versus Individual Antenatal Care (ANC) on Quality of Care, ANC Attendance and Facility-Based Delivery: A Pragmatic Cluster-Randomized Controlled Trial in Kenya and Nigeria’, PLOS ONE 14, no. 10: e0222177, doi:10.1371/journal.pone.0222177.

    • Search Google Scholar
    • Export Citation
  • Harman, S. (2016), ‘Ebola, Gender and Conspicuously Invisible Women in Global Health Governance’, Third World Quarterly 37, no. 3: 524541, doi:10.1080/01436597.2015.1108827.

    • Search Google Scholar
    • Export Citation
  • Harman, S. (2021), ‘Threat Not Solution: Gender, Global Health Security and COVID-19’, International Affairs 97, no. 3: 601623, doi:10.1093/ia/iiab012.

    • Search Google Scholar
    • Export Citation
  • Heidari S, C. Ahumada, Z. Kurbanova and GENDRO (Gender, Evidence and Health Network) (2020), ‘Towards the Real-Time Inclusion of Sex- and Age-Disaggregated Data in Pandemic Responses’, BMJ Global Health 5: e003848, doi:10.1136/bmjgh-2020-003848.

    • Search Google Scholar
    • Export Citation
  • JICA (Japan International Cooperation Agency) (2017), The Socio-Economic Situation and Gender in the DRC, March, Country Gender Profile Democratic Republic of the Congo Final Report, https://www.jica.go.jp/english/our_work/thematic_issues/gender/background/c8h0vm0000anjqj6-att/drc_2017.pdf.

    • Search Google Scholar
    • Export Citation
  • Jones S. A., S. Gopalakrishnan, C. A. Ameh, S. White and N. R. Van den Broek (2016), ‘Women and Babies Are Dying but Not of Ebola: The Effect of the Ebola Virus Epidemic on the Availability, Uptake and Outcomes of Maternal and Newborn Health Services in Sierra Leone’, BMJ Global Health 1, no. 3: e000065, doi:10.1136/bmjgh-2016-000065.

    • Search Google Scholar
    • Export Citation
  • IMF (2015), Taking Stock of Poverty in the Democratic Republic of the Congo, October, Country Report No. 15, https://www.imf.org/external/pubs/ft/scr/2015/cr15281.pdf.

    • Search Google Scholar
    • Export Citation
  • INS (Institut National de la Statistique) (2020), ‘Mesure de l'impact du COVID-19 sur les Unités Economiques’ [Measuring the impact of COVID-19 on economic units], Bulletin Numero 1, July, World Bank, https://fscluster.org/sites/default/files/documents/covid19-rdc-snapshot_principaux_resultats_entreprises_20200730vf1.pdf.

    • Search Google Scholar
    • Export Citation
  • Lieberman, A. (2021), ‘Where Are the Women in Food Insecurity Analysis?Devex, 4 January, https://www.devex.com/news/where-are-the-women-in-food-insecurity-analysis-98804.

    • Search Google Scholar
    • Export Citation
  • MDM (Médecins du Monde) (2020), ‘Santé Sexuelle et Reproductive Pour les Jeunes & Adolescents (10–24 ans) à Kinshasa et l'Impact de la COVID-19’ [Sexual and reproductive health for youth and adolescents (10–24 years) in Kinshasa and the impact of COVID-19], paper presented at CASS Impacts of COVID-19 Workshop, October.

    • Search Google Scholar
    • Export Citation
  • Pellecchia, U., R. Crestani, T. Decroo, R. Van den Bergh and Y. Al-Kourdi (2015), ‘Social Consequences of Ebola Containment Measures in Liberia’, PLOS ONE 10, no. 12: e0143036, doi:10.1371/journal.pone.0143036.

    • Search Google Scholar
    • Export Citation
  • Perez, C. (2019), Invisible Women: Data Bias in a World Designed for Men (New York: Abrams Press).

  • Ripoll, S., I. Gercama, T. Jones and A. Wilkinson (2018), Social Science in Epidemics: Ebola Virus Disease Lessons Learned – Background Report, December, UNICEF, https://reliefweb.int/sites/reliefweb.int/files/resources/Final_Ebola_lessons_learned_full_report.pdf.

    • Search Google Scholar
    • Export Citation
  • Stark, L., M. Meinhart, L. Vahedi, S. E. Carter, E. Roesch, I. Scott Moncrieff, … and C. Poulton (2020), ‘The Syndemic of COVID-19 and Gender-Based Violence in Humanitarian Settings: Leveraging Lessons from Ebola in the Democratic Republic of Congo’, BMJ Global Health 5, no. 11: e004194, doi:10.1136/bmjgh-2020-004194.

    • Search Google Scholar
    • Export Citation
  • Strong, A. E. and D. A. Schwartz (2018), ‘Effects of the West African Ebola Epidemic on Health Care of Pregnant Women: Stigmatization With and Without Infection’, Pregnant in the Time of Ebola: Women and Their Children in the 2013–2015 West African Epidemic 2019: 1130, doi:10.1007/978-3-319-97637-2_2.

    • Search Google Scholar
    • Export Citation
  • UNDP (2020), ‘Results of the Surveys on the Socio-Economic Impact of COVID-19’, paper presented at the CASS Workshop on the Broader Impacts of COVID-19 in the DRC, 1 October 2021.

    • Search Google Scholar
    • Export Citation
  • UNICEF (2019), Egalité des sexes: ou en-sommes en RDC [Equality of the sexes: Where we are at in the DRC], July, Multiple Indicator Cluster Survey, https://www.unicef.org/drcongo/rapports/resume-mics-palu-2017-2018.

    • Search Google Scholar
    • Export Citation
  • WANEP (West Africa Network for Peace-Building) (2020), The Impact of COVID-19 Pandemic on Women: Lessons from the Ebola Outbreak in West Africa, June, https://www.preventionweb.net/files/73779_thematicreportfinaltheimpactofcovid.pdf.

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