Our study found that the overall WHODAS score in our population was high [Med (IQR) = 25 (6.3–41.7)], mostly in unstable HZs [Med (IQR) = 39.6 (22.9–54.2)] indicating an overall low health status for the population in this area. The RA and IHZs had globally identical scores and more precisely on the items concerning the cognitive and social aspects. The socio-cultural and demographic characteristics of the participants as well as the type of HZ were associated with the WHODAS score, explaining respectively 17.7% and 13.5% of its variance. The factors significantly associated with an overall poor health status (or higher whodas score) were; advanced age, being woman, being membership of an association, being divorced, separated or widower and living in an unstable HZ.
The health status of the population in crisis situations related to the armed conflicts
In our study, the median WHODAS score in the unstable HZ was 39.6, which was significantly higher than in the stable HZ (6.3 and 25,0) or even intermediate (22.9). The median score of UHZ would then be found in the 10% of the class with severely impaired disability (40). Even if there is no consensus on the cut-point defining people with an altered health condition from the WHODAS score (40), our results confirm that the populations living in UHZ have a more impaired health status than those living in stable areas.
We note that the deterioration in the health status of the population living in UHZ in South Kivu concerns all six areas of disability, more particularly the cognitive aspects [Med (IQR) = 3 (2–5)], the execution of daily tasks [Med (IQR) = 4 (2–6)], mobility [Med (IQR) = 4 (2–6)] and participation in the social life of the community [Med (IQR) = 4 (2–5)]. Indeed, armed conflicts create a climate of insecurity and impact on the socio-economic and psychological daily lives of people(11, 42). WHODAS 2.0 has proven to be an effective tool for assessing disability caused by post-traumatic stress disorder (43). The chronic crisis related to armed conflicts can be a stressful situation which can lead to a serious physical, psycho-social and mental handicap. The deterioration of cognitive aspects can be justified by the fact that armed conflicts quite often lead to mental disorders (44–46). The prevalence of these disorders is estimated to be around 30% in the population affected by these conflicts (44, 47). People live in fear of being attacked again and no longer go about their daily tasks. Unfortunately, most of them, as our study shows (58%), live on small trade in their local products. The destruction of infrastructure (as well as health structures), the theft of property and physical assault affect emotionally and destroys the community life of the victims.
Our study also showed that aspects related to social life [Med (IQR) = 1 (0–4)] and self-care [Med (IQR) = 1 (0–3)] were the least affected in a crisis setting. This could be explained by the fact that in crisis settings people are more likely to help each other in order to ensure their survival. Furthermore, the crisis also leads to frequent displacement of populations, pushing people to live in temporary housing, as shown in our results. This nomadic life will expose the population to communicable and rapidly fatal diseases mainly due to the lack of drinking water and a very poor environmental sanitation. (48, 49).
The RS HZ had an overall WHODAS score statistically identical to that of the IHZ. This suggests that isolation during armed conflict could in itself be a factor that can influence the health status of the population. Indeed, it has been noted that populations living in rural and isolated regions are vulnerable in terms of health (50). Vulnerability, which may increase during armed conflicts in neighboring regions, is mainly due to the shortage of healthcare infrastructure and qualified healthcare personnel in these regions (51).
Factors associated with variance in WHODAS score
Our second hierarchical regression model showed that socio-cultural and demographic factors account for 19% of the variance in the WHODAS score in our population. The score increases with age (B = 0.356; p < 0.001) and the female sex (B = 5.776; p < 0.001). This corroborates with the results of some authors (40, 52). Indeed, it is especially the health status of vulnerable people (women, children, elderly people) which deteriorates during armed conflicts (53–55). This could be linked to the fact that it is women who are most often ill-treated (54), children and elderly people find it difficult to adapt to the nomadic life created by displacement during armed conflict. Also, the latter have a relative immunosuppression that can expose them to communicable diseases which are among the most frequent causes of death during armed conflicts (56, 57).
We also note that the WHODAS score decreases in people living in more and more comfortable dwellings (B = -1.838; p = 0.014). Indeed, having a sustainable and permanent habitat would be a fact which can protect people from environmental and psycho-social risks. It is often people who have not moved in armed conflict who may have these types of accommodation, while IDPs often stay in camps with poorly sanitized permanent accommodation.
Our results also show that the individual's health status improves if he or she does not have a formal job (B= -1.334; p = 0.002), which is rather curious. Nevertheless, in situations of armed conflict, since it is the psycho-social aspects that are affected, the unemployed may be favored. Indeed, they may have a lot of time to take care of themselves, be more present in their community and may be less stressed by the demands of work.
Our results also suggest that being separated/divorced/widower (B = 2.147; p = 0.003) and being a membership of an association (B = 5.944; p < 0.001) were associated with higher whodas score. These factors can be decisive in the sense that a person's state of health also depends on his relationship with others and the socio-economic climate that prevails around him. The fact that most of the armed conflicts in South Kivu are due to land and tribe issues (58), further alters the socio-economic dynamics of the population living in these conflict zones.
On the other hand, being a member of an association should rather help to better support the crisis situation. Nevertheless, this could be explained by the fact that during periods of conflict, the created associations are dissolved, leading to a setback in the economic life of the person.
This model also showed that the UHZ (crisis areas) explains the variance in the WHODAS score of the population living there at 13.5%. People living in “crisis” health zones had increasingly higher WHODAS scores (B = 6,780; p < 0.001). These results are in line with those of several authors who have found that armed conflicts have a negative impact on the state of health of the population and in several other areas of daily life (4, 55, 59, 60)
Strenghts and limitations
Some limitations of our work are worth discussing. Firstly, concerning the selection of health areas and participants: three health areas initially chosen at random were not visited due to accessibility and insecurity issues. However, they were replaced by three other HA contiguous to the previous ones, better accessible and more secure, which could have the same socio-cultural characteristics. Also, it was more likely that people who went to work could not be found when visiting homes. Thus, we have implemented a double pass system so that all inhabitants have the chance to participate in our study. Second, the fact that the WHODAS tool was not translated into local language (Kibembe, Kitembo, Kirega, Mashi) may affect understanding of the questions. To minimize this, we ensured a good translation of the tool in French and Swahili by a language school according to the principle of translation and counter-transduction advocated by WHO and we pre-tested it. Also, we chose doctors as investigators, guided locally by a community leader. Finally, it is difficult to generalize these results to the entire population (note that we used only 6 on 34 HZs of South Kivu), especially since each community lives in a very specific and very often complex state of crisis. The state of health in this case is the result of several other individual, socio-cultural and environmental parameters which are difficult to grasp. However, our study shows that living in a crisis HZ is an important factor contributing to the deterioration of people's health.
Our study nevertheless presents some strengths. It is among the first to study the state of health of the general population in areas affected by crises related to armed conflicts in South Kivu. This is particular, especially since in most cases, the health status of the population is assessed through disease-based or heath programs indicators for the management of these diseases. WHODAS allowed us to see the state of the population’s health from a broader perspective, linked to development capacity. This could guide policy makers to have a second view of the real health status of the population, especially those in regions of chronic crisis.