Aflatoxins contents determination in some foodstuffs in Burkina Faso and human health risk assessment.

Aflatoxins are produced by fungi of the genus Aspergillus that colonize many foodstuffs during agricultural production, harvesting, transportation, storage, and food processing. In view of these aflatoxins toxicity to humans, their presence in foods such as cereals and oilseeds constitutes a major challenge for global food security, health and nutrition. This study was therefore initiated to assess the level of aflatoxin contamination of various foodstuffs sold in urban and semi-urban markets in Burkina Faso, and to evaluate the carcinogenic risk which the consuming population is exposed to. Two hundred and twelve foodstuff samples were collected in two large cities (Ouagadougou and Bobo Dioulasso) and three semi urban localities (Cinkansé, Dakola and Niangoloko). Aflatoxins contents in foodstuffs were determined by immunoaffinity chromatography and human health risk assessment was performed by using the Monte Carlo algorithm. The aflatoxins contents determination showed that 41.50% of studied samples were contaminated with concentrations up to 182.28 µg/kg for AFB1 in peanuts. Chronic Daily Intake, calculated based on the consumption patterns assumed in this study, was estimated to be higher in large cities (CDI = 33.68 µg/kg bw in Ouagadougou and 10.18 µg/kg bw in Bobo Dioulasso) than in semi urban localities (CDI = 4.29 µg/kg bw in Cinkansé, CDI = 0.39 µg/kg bw in Dakola and CDI = 0.18 µg/kg bw in Niangoloko). The MOE determination showed that the sorghum meal and whole grain maize consumption was associated to the carcinogenic risk for public health in large cities (the percentile 95 of MOE = 3316 for rice, 4511 for peanuts, 3334 for sorghum meal and 4530 for whole grain maize). In semi urban localities, no carcinogenic risk was observed to public health. These results should inspire the country's sanitary and agricultural authorities to undertake actions to fight against the agricultural food products contamination by aflatoxins in order to safeguard the population's health.

Nutritional, Microbiological, and Toxicological Quality Assessment of Foods Sold in Urban and Suburban Markets in Burkina Faso.

Food safety risks are becoming a public health problem with important socioeconomic consequences for human wellbeing, especially for pregnant women and infants. In this article, we describe findings from microbiological, toxicological, and nutritional quality assessments of foods from 5 localities in Burkina Faso, with the aim to provide baseline data on the quality of food and the risks to mothers and children. Samples for assessment included food sold in markets, stores, and restaurants (eg, cereals, oilseeds, vegetables, edible oils, powdered milk, dried fish, packaged water, ready-to-eat meals). The research team selected the samples using the random route method and analyzed them at the National Public Health Laboratory in Ouagadougou between January and December 2020. A total of 443 food samples were collected, of which 101 were analyzed for microbial contamination, 360 were analyzed for the presence of toxins, and 59 were analyzed for their nutritional value. The microbiological quality of 11.88% of the food samples was unsatisfactory, and 41.50% were contaminated with aflatoxins. At least 1 pesticide residue and cyfluthrin were detected in 58.10% of samples. The most detected contaminant (cyfluthrin) was found in 79.10% of the analyzed samples. A peroxide index higher than the normal value (10 mEq/kg) was found in 3.38% of the oil samples and 76.27% of the oil samples had a vitamin A content lower than the recommended limit of 11 mg/kg. This study is the first in Burkina Faso that provides baseline data on the quality of food and potential health risks to mothers and children in Burkina Faso. Considering the level of contaminants reported in this article, it is imperative to enhance routine monitoring of foods in the country.

Microbiological quality assessment of five common foods sold at different points of sale in Burkina-Faso.

The aim of the present study was to assess the microbial quality of five ready-to-eat food such as bread, pasta, rice with sauce, beans and milk sold in five localities of Burkina Faso namely, Ouagadougou, Bobo-Dioulasso, Dakola, Cinkansé and Niangoloko. One hundred and one samples were collected and microbial quality were assessed by evaluating the food hygiene indicators such as total aerobic mesophilic flora, total coliforms, thermotolerant coliforms, yeast and mould. Food safety indicators such as Escherichia coli, Salmonella, coagulase-positive staphylococci, Clostridium perfringens and Bacillus cereus were also tested for contamination. Samples were tested according to ISO guidelines for all parameters. The results showed that 74 (73.27%) of samples were satisfactory while 15 (14.85%) were acceptable and 12 (11.88%) were not satisfactory according to international standards. Among the food safety indicators sought, Escherichia coli was detected in two samples and Bacillus cereus in four samples. Most of the analyzed food exhibited good hygiene behavior within the acceptable limits and the highest of not satisfactory rate was observed in milk powder and rice with sauce. Ouagadougou samples recorded the highest number of not satisfactory samples. Despite the general quality was satisfactory, the presence of specific microorganisms such as coliforms is indicative of the poor hygiene surrounded these foods. It is therefore necessary to train and follow up the vendors in the handling of equipment, hand-washing practices and selling environment hygiene for better improvement of the quality of the street foods.

Evaluation of metallic trace elements contents in some major raw foodstuffs in Burkina Faso and health risk assessment.

Diet based on cereal, vegetables, oleaginous and dried fish are providing essential metallic elements. It can be also a source of exposure to toxic metallic elements. The aims of this study were to evaluate the contents on nine metallic trace elements (Fe, Zn, Mn, Co, Cd, Pb, Cu, Ni, Cr) in some major raw foodstuffs including rice, maize, peanut, tomato and dried fish in Burkina Faso and assess the health risk of these elements. Two hundred twenty-two samples were collected and analyzed by atomic absorption spectrometry. The health risk assessment was based on the United States Environment Protection Agency (USEPA) model. Iron and Zinc were the elements with the highest concentrations in the investigated foodstuffs. The iron highest median value (68.80 mg/kg) was observed in dried fish followed by maize (43.09 mg/kg) and peanuts (28.92 mg/kg). Rates of 77.95%, 66.66% and 32.5% obtained respectively fro tomato, maize and rice samples were above the maximum limit of lead set by Codex Alimentarius while 47.6%, 71.16% and 0% of maize, tomato and rice samples respectively have shown concentration above the maximum limit of cadmium. Chromium had shown higher contribution rate to the maximum daily intake of 167.11%, 34%, 2% and 8.53% for rice, maize and peanut respectively. A non-cancer risk situation has been observed on rice, maize and peanut consumption. None of the index risk values was above the threshold set by USEPA.

Can Combining Performance-Based Financing With Equity Measures Result in Greater Equity in Utilization of Maternal Care Services? Evidence From Burkina Faso.

BACKGROUND: As countries reform health financing systems towards universal health coverage, increasing concerns emerge on the need to ensure inclusion of the most vulnerable segments of society, working to counteract existing inequities in service coverage. To this end, selected countries in sub-Saharan Africa have decided to couple performance-based financing (PBF) with demand-side equity measures. Still, evidence on the equity impacts of these more complex PBF models is largely lacking. We aimed at filling this gap in knowledge by assessing the equity impact of PBF combined with equity measures on utilization of maternal health services in Burkina Faso. METHODS: Our study took place in 24 districts in rural Burkina Faso. We implemented an experimental design (clusterrandomized trial) nested within a quasi-experimental one (pre- and post-test design with independent controls). Our analysis relied on self-reported data on pregnancy history from 9999 (baseline) and 11 010 (endline) women of reproductive age (15-49 years) on use of maternal healthcare and reproductive health services, and estimated effects using a difference-in-differences (DID) approach, purposely focused on identifying program effects among the poorest wealth quintile. RESULTS: PBF improved the utilization of few selected maternal health services compared to status quo service provision. These benefits, however, were not accrued by the poorest 20%, but rather by the other quintiles. PBF combined with equity measures did not produce better or more equitable results than standard PBF, with specific differences only on selected outcomes. CONCLUSION: Our findings challenge the notion that implementing equity measures alongside PBF is sufficient to produce an equitable distribution in program benefits and point at the need to identify more innovative and contextsensitive measures to ensure adequate access to care for the poorest. Our findings also highlight the importance of considering changing policy environments and the need to assess interferences across policies.

Impact of Performance-Based Financing on effective coverage for curative child health services in Burkina Faso: Evidence from a quasi-experimental design.

OBJECTIVE: To evaluate the impact of Performance-Based Financing (PBF) on effective coverage of child curative health services in primary healthcare facilities in Burkina Faso. METHODS: An impact evaluation of a PBF pilot programme, using an experiment nested within a quasi-experimental design, was carried out in 12 intervention and 12 comparison districts in six regions of Burkina Faso. Across the 24 districts, primary healthcare facilities (537 both at baseline and endline) and households (baseline = 7978 endline = 7898) were surveyed. Within these households, 12 350 and 15 021 under-five-year-olds caretakers were interviewed at baseline and endline respectively. Linking service quality to service utilisation, we used difference-in-differences to estimate the impact of PBF on effective coverage of curative child health services. RESULTS: Our study failed to detect any effect of PBF on effective coverage. Looking specifically into quality of care indicators, we detected a positive effect of PBF on structural elements of quality of care related to general service readiness, but not on the overall facility quality score, capturing both service readiness and the content of childcare. CONCLUSION: The current study makes a unique contribution to PBF literature, as this is the first study assessing PBF impact on effective coverage for curative child health services in low-income settings. The absence of any significant effects of PBF on effective coverage suggests that PBF programmes require a stronger design focus on quality of care elements especially when implemented in a context of free healthcare policy.

Patterns of healthcare seeking among people reporting chronic conditions in rural sub-Saharan Africa: findings from a population-based study in Burkina Faso.

OBJECTIVE: Non-communicable diseases are rapidly becoming one of the leading causes of morbidity and mortality in sub-Saharan Africa. Yet, little is known about patterns of healthcare seeking among people with chronic conditions in these settings. We aimed to explore determinants of healthcare seeking among people who reported at least one chronic condition in rural Burkina Faso. METHODS: Data were drawn from a cross-sectional population-based survey conducted across 24 districts on 52 562 individuals from March to June 2017. We used multinomial logistic regression to assess factors associated with seeking care at a formal provider (facility-based care) or at an informal provider (home and traditional treatment) compared to no care. RESULTS: 1124 individuals (2% of all respondents) reported at least one chronic condition. Among those, 22.8% reported formal care use, 10.6% informal care use, and 66.6% no care. The presence of other household members reporting a chronic condition (RRR = 0.57, 95%-CI [0.39, 0.82]) was negatively associated with seeking formal care. Wealthier households (RRR = 2.14, 95%-CI [1.26, 3.64]), perceived illness severity (RRR = 3.23, 95%-CI [2.22, 4.70]) and suffering from major chronic conditions (RRR = 1.54, 95%-CI [1.13, 2.11]) were positively associated with seeking formal care. CONCLUSION: Only a minority of individuals with chronic conditions sought formal care, with important differences due to socio-economic status. Policies and interventions aimed at increasing the availability and affordability of services for early detection and management in peripheral settings should be prioritised.

OBJECTIF: Les maladies non transmissibles deviennent rapidement l'une des principales causes de morbidité et de mortalité en Afrique subsaharienne. Pourtant, on en sait peu sur les profils de recherche de soins de santé chez les personnes atteintes de maladies chroniques dans ces milieux. Nous visions à explorer les déterminants de la recherche de soins de santé chez les personnes qui ont déclaré au moins une maladie chronique dans les régions rurales du Burkina Faso. MÉTHODES: Les données ont été tirées d'une enquête transversale de population menée dans 24 districts auprès de 52.562 personnes de mars à juin 2017. Nous avons utilisé une régression logistique multinomiale pour évaluer les facteurs associés à la recherche de soins chez un prestataire formels (soins en établissement) ou chez un prestataire informel (traitement à domicile et traditionnel) par rapport à l'absence de soins. RÉSULTATS: 1.124 personnes (2% de tous les répondants) ont déclaré au moins une maladie chronique. Parmi ceux-ci, 22,8% ont déclaré avoir recours à des soins formels, 10,6% à des soins informels et 66,6% à aucun soin. La présence d'autres membres du ménage déclarant une maladie chronique (RRR = 0,57, IC95%: 0,39, 0,82) était associée négativement à la recherche de soins formels. Les ménages plus riches (RRR = 2,14; IC95%: 1,26-3,64), la sévérité perçue de la maladie (RRR = 3,23 ; IC95%: 2,22-4,70) et souffrir de maladies chroniques majeures (RRR = 1,54 ; IC95%: 1,13-2,11) étaient positivement associés à la recherche de soins formels. CONCLUSION: Seule une minorité de personnes atteintes de maladies chroniques ont recherché des soins formels, avec des différences importantes en raison du statut socioéconomique. Les politiques et interventions visant à accroître la disponibilité et l'accessibilité des services de détection précoce et de prise en charge dans les régions périphériques doivent être prioritaires.

Correction to: Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso.

Due to an error introduced during copyediting of this article [1], there are two corrections about the Figs. 1. The caption of Fig. 1 should be changed to "Study design". 2. The Fig. 2 is missing.

Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso.

BACKGROUND: The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. METHODS: This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. DISCUSSION: We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention's impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. TRIAL REGISTRATION: Registered with RIDIE (RIDIE-STUDY-ID- 54412a964bce8 ) on 10/17/2014.

Factors associated with effective coverage of child health services in Burkina Faso.

OBJECTIVE: To identify factors associated with both crude and effective health service coverage of under-fives in rural Burkina Faso. METHODS: In a cross-sectional study, 494 first-line health facilities, 7347 households and 12 497 under-fives were surveyed. Two sequential logistic random effects models were conducted to assess factors associated with crude and effective coverage. RESULTS: Of 614 children under-five with a reported illness episode, 427 (69.5%) received care at a health facility. Of those, 274 (64.1%) received care at a health facility providing at least the minimum threshold of service quality. We found that younger age, having a severe illness, shorter distance between household and health facility, and being from wealthier households were positively associated with crude coverage. In addition, low patient caseload and longer consultation had a positive association, while frequent facility supervisions had a negative association with effective coverage. Moreover, the nurse to clinical staff ratio at the health facility was positively associated with both crude and effective coverage. CONCLUSION: Our study found that crude coverage is associated with pre-disposing and enabling factors of health care access, while the availability of nurses is a strong predictor for both crude and effective coverage. This suggests that in the context of scarcity of resources, investing in human resources in health sector could be one of the priorities for decision-makers to ensure children in need not only access to healthcare but also good quality of care.

Measuring effective coverage of curative child health services in rural Burkina Faso: a cross-sectional study.

OBJECTIVE: To estimate both crude and effective curative health services coverage provided by rural health facilities to under 5-year-old (U5YO) children in Burkina Faso. METHODS: We surveyed 1298 child health providers and 1681 clinical cases across 494 primary-level health facilities, as well as 12 497 U5YO children across 7347households in the facilities' catchment areas. Facilities were scored based on a set of indicators along three quality-of-care dimensions: management of common childhood diseases, management of severe childhood diseases and general service readiness. Linking service quality to service utilisation, we estimated both crude and effective coverage of U5YO children by these selected curative services. RESULTS: Measured performance quality among facilities was generally low with only 12.7% of facilities surveyed reaching our definition of high and 57.1% our definition of intermediate quality of care. The crude coverage was 69.5% while the effective coverages indicated that 5.3% and 44.6% of children reporting an illness episode received services of only high or high and intermediate quality, respectively. CONCLUSION: Our study showed that the quality of U5YO child health services provided by primary-level health facilities in Burkina Faso was low, resulting in relatively ineffective population coverage. Poor adherence to clinical treatment guidelines combined with the lack of equipment and qualified clinical staff that performed U5YO consultations seemed to be contributors to the gap between crude and effective coverage.

Street-level workers' inadequate knowledge and application of exemption policies in Burkina Faso jeopardize the achievement of universal health coverage: evidence from a cross-sectional survey.

BACKGROUND: Street-level workers play a key role in public health policies in Africa, as they are often the ones to ensure their implementation. In Burkina Faso, the State formulated two different user-fee exemption policies for indigents, one for deliveries (2007), and one for primary healthcare (2009). The objective of this study was to measure and understand the determinants of street-level workers' knowledge and application of these exemption measures. METHODS: We used cross-sectional data collected between October 2013 and March 2014. The survey targeted 1521 health workers distributed in 498 first-line centres, 18 district hospitals, 5 regional hospitals, and 11 private or other facilities across 24 districts. We used four different random effects models to identify factors associated with knowledge and application of each of the above-mentioned exemption policies. RESULTS: Only 9.2% of workers surveyed knew of the directive exempting the worst-off, and only 5% implemented it. Knowledge and application of the delivery exemption were higher, with 27% of all health workers being aware of the delivery exemption directive and 24.2% applying it. Mobile health workers were found to be consistently more likely to apply both exemptions. Health workers who were facility heads were significantly more likely to know about the indigent exemption for primary health care and to apply it. Health workers in districts with higher proportions of very poor people were significantly more likely to know about and apply the delivery exemption. Nearly 60% of respondents indicated either 5% or 10% as the percentage of people they would deem adequate to target for exemption. CONCLUSION: This quantitative study confirmed earlier qualitative results on the importance of training and informing health workers and monitoring the measures targeting equity, to ensure compliance with government directives. The local context (e.g., hierarchy, health system, interventions) and the ideas that street-level workers have about the policy instruments can influence their effective implementation. Methods for remunerating health workers and health centres also need to be adapted to ensure equity measures are applied to achieve universal healthcare.

Determinants of unmet need for family planning in rural Burkina Faso: a multilevel logistic regression analysis.

BACKGROUND: Unmet need for family planning has implications for women and their families, such as unsafe abortion, physical abuse, and poor maternal health. Contraceptive knowledge has increased across low-income settings, yet unmet need remains high with little information on the factors explaining it. This study assessed factors associated with unmet need among pregnant women in rural Burkina Faso. METHOD: We collected data on pregnant women through a population-based survey conducted in 24 rural districts between October 2013 and March 2014. Multivariate multilevel logistic regression was used to assess the association between unmet need for family planning and a selection of relevant demand- and supply-side factors. RESULTS: Of the 1309 pregnant women covered in the survey, 239 (18.26%) reported experiencing unmet need for family planning. Pregnant women with more than three living children [OR = 1.80; 95% CI (1.11-2.91)], those with a child younger than 1 year [OR = 1.75; 95% CI (1.04-2.97)], pregnant women whose partners disapproves contraceptive use [OR = 1.51; 95% CI (1.03-2.21)] and women who desired fewer children compared to their partners preferred number of children [OR = 1.907; 95% CI (1.361-2.672)] were significantly more likely to experience unmet need for family planning, while health staff training in family planning logistics management (OR = 0.46; 95% CI (0.24-0.73)] was associated with a lower probability of experiencing unmet need for family planning. CONCLUSION: Findings suggest the need to strengthen family planning interventions in Burkina Faso to ensure greater uptake of contraceptive use and thus reduce unmet need for family planning.

Factors Associated with Contraceptive Use among Women of Reproductive Age in Rural Districts of Burkina Faso.

Given the current low contraceptive use and corresponding high levels of unwanted pregnancies leading to induced abortions and poor maternal health outcomes among rural populations, a detailed understanding of the factors that limit contraceptive use is essential. Our study investigated household and health facility factors that influence contraceptive use decisions among rural women in rural Burkina Faso. We collected data on fertile non-pregnant women in 24 rural districts in 2014. Of 8,657 women, 1,098 used a modern contraceptive. Women having a living son, a child younger than one year, and household wealth were more likely to use modern contraceptives. Women in polygamous marriages and women living at least 5 kilometers from a health facility were less likely to use contraception. We conclude that modern contraceptive use remains weak, hence, programs aiming to encourage contraceptive use must address barriers at both the health facility and the household level.

Protocol for the process evaluation of interventions combining performance-based financing with health equity in Burkina Faso.

BACKGROUND: The low quality of healthcare and the presence of user fees in Burkina Faso contribute to low utilization of healthcare and elevated levels of mortality. To improve access to high-quality healthcare and equity, national authorities are testing different intervention arms that combine performance-based financing with community-based health insurance and pro-poor targeting. There is a need to evaluate the implementation of these unique approaches. We developed a research protocol to analyze the conditions that led to the emergence of these intervention arms, the fidelity between the activities initially planned and those conducted, the implementation and adaptation processes, the sustainability of the interventions, the possibilities for scaling them up, and their ethical implications. METHODS/DESIGN: The study adopts a longitudinal multiple case study design with several embedded levels of analyses. To represent the diversity of contexts where the intervention arms are carried out, we will select three districts. Within districts, we will select both primary healthcare centers (n =18) representing different intervention arms and the district or regional hospital (n =3). We will select contrasted cases in relation to their initial performance (good, fair, poor). Over a period of 18 months, we will use quantitative and qualitative data collection and analytical tools to study these cases including in-depth interviews, participatory observation, research diaries, and questionnaires. We will give more weight to qualitative methods compared to quantitative methods. DISCUSSION: Performance-based financing is expanding rapidly across low- and middle-income countries. The results of this study will enable researchers and decision makers to gain a better understanding of the factors that can influence the implementation and the sustainability of complex interventions aiming to increase healthcare quality as well as equity.

Healthcare-associated infection in Burkina Faso: an assessment in a district hospital.

In developing countries, few data are available on healthcare-associated infections. In Burkina Faso, there has been a failure to take into account risk management and patient safety in the quality assurance program. The main objective of our study was to carry out an assessment of healthcare-associated infection in a first level hospital. We conducted a cross-sectional study in June 2011 in the care units of Ziniaré District Hospital (Ziniaré, Burkina Faso). The hospital has been divided in three components: i) hospital population (care providers, in-patients and patients' guardians); ii) healthcare and services organization; iii) hospital environment. We included: care providers of the clinical services, hospital in-patients and patients' guardians, hospitalization infrastructure and nursing units, and all the documents relating to standards and protocols. Data collection has been done by direct observation, interviews and biological samples taken at different settings. In hospital population, care providers and patients' guardians represented a high source of infection: adherence to hygiene practice on the part of care providers was low (12/19), and no patients' guardian experienced good conditions of staying in the hospital. In healthcare and services organization, healthcare waste management represented a high-risk source of infection. In hospital environment, hygiene level of the infrastructure in the hospital rooms was low (6.67%). Prevalence of isolated bacteria was 71.8%. Urinary-tract catheters infections were the most significant in our sample, followed by surgical-site infections. In total, 56.26% (9/19) of germs were -Lactamase producers (ESBL). They were represented by Escherichia coli and Klebsiella pneumoniae. Our analysis identified clearly healthcare-associated infection as a problem in Ziniaré district hospital. Hence, a national program of quality assurance in the hospitals should now integrate the risk infectious management of healthcare-associated infections.