Eight years into the horizon of aspirational maternal and newborn health pledges: a nationwide cross-sectional exploration of the Burundian EmONC network capacity and budget deficits.

OBJECTIVE: The Burundian emergency obstetric and neonatal care (EmONC) programme, which was initiated in 2017 and supported by a specific policy, does not appear to reverse maternal and newborn mortality trends. Our study examined the capacity challenges facing participating EmONC facilities and developed alternative investment proposals to improve their readiness paying particular attention to EmONC professionals, physical infrastructure, and capital equipment. DESIGN: Cross-sectional study. SETTING: Burundian EmONC facilities (n=112). PARTICIPANTS: We examined EmONC policy documents, consulted 12 maternal and newborn health experts and 23 stakeholders and policymakers, surveyed all EmONC facilities (n=112), and collected cost data from the Ministry of Health and local suppliers in Burundi. We developed three context-specific EmONC resource benchmark standards by facility type; the Burundian policy norms and the expert minimum and maximum suggested thresholds; and used these alternatives to estimate EmONC resource gaps. We forecasted three corresponding budget estimates needed to address prevailing deficits taking a government perspective for a 5-year EmONC investment strategy. Additionally, we explored relationships between EmONC professionals and selected measures of service delivery using bivariate analyses and graphically. RESULTS: The lowest EmONC resource benchmark revealed that 95% of basic EmONC and all comprehensive EmONC facilities lack corresponding sets of human resources and 90% of all facilities need additional physical infrastructure and capital equipment. Assessed against the highest benchmark which proposes the most progressive set of standards for the prevailing workloads, Burundi would require 162 more medical doctors, 1005 midwives and nurses, 132 delivery rooms, 191 delivery tables, 678 and 156 maternity and newborn care beds, and 395 incubators amounting to US$32.9 million additional budget for 5 years. CONCLUSION: We demonstrated that Burundian EmONC facilities face enormous capacity challenges equivalent to US$32.9 million funding gap for 5 years; averagely approximating to 5.96% total health budget increase annually.

Prevalence and associated risk factors assessment of bovine fasciolosis in the Imbo Region, Burundi.

Fasciolosis is a zoonosis that limits the productivity of ruminants worldwide, but there is a lack of information on its occurrence in Burundi. Therefore, this study aimed to fill the information gap by determining the prevalence and risk factors associated with bovine fasciolosis in the Imbo Region of Burundi. Two prevalence studies were conducted in parallel in the five communes of the five provinces in the Imbo region. In the first study, a total of 426 fecal samples were collected from randomly selected cattle farms and microscopically examined to determine Fasciola egg burden. Survey data on cattle husbandry were collected from owners of these cattle and analyzed to determine the risk factors for bovine fasciolosis. In the second study, 467 cattle were randomly selected in abattoirs and their livers were examined postmortem to determine liver fluke burdens. Data were entered separately into Microsoft Excel and analyzed using R software. The overall prevalence of bovine fasciolosis was 47.7% (42.9-52.4, 95% CI) for microscopic examination and 33.2% (28.9-37.5, 95% CI) for postmortem examinations. The majority of positive cattle (60.6%) had light intensity infections as determined by eggs per gram of feces (epg). Postmortem examinations corroborated these results and indicated that 80% of cattle had light intensity infections. Chi-square analysis showed a statistical association with the presence of bovine fasciolosis and the age, sex, and origin of cattle and the practices of cattle owners (P < 0.05).

Heterogeneous effects of socio-economic and cultural factors on fertility differentials in Burundi and Morocco during their fertility transition periods: a retrospective, cross-sectional and comparative study.

Introduction: few studies have examined the factors influencing fertility differentials and the variation in their effects in countries with different socioeconomic and cultural backgrounds and different fertility transition paces. To address this gap, our study sought to first identify the factors that influenced fertility differentials in Morocco and Burundi during their fertility transition periods, and then to compare the effects of these factors between the two countries. Methods: using data from the 2003-4 Morocco and 2010 Burundi Demographic and Health Surveys, bivariable and multivariable Poisson regression analyses offset by the natural logarithm of the women´s age were performed to identify the socioeconomic and cultural factors that influenced fertility differentials in Morocco and Burundi during their fertility transition. Results: our main findings showed that the total number of children ever born ranged from 0 to 17 with a mean of 2.71 ± 2.89 in Burundi and from 0 to 16 with a mean of 1.88 ± 2.80 in Morocco. In Burundi, both socioeconomic and cultural factors like rural residence adjusted incident rate ratio (AIRR) = 1.159, 95% CI: 1.103 - 1.217, P=0.020), women´s illiteracy (AIRR=1.465, 95% CI: 1.241- 1.729, P <0.001) and agricultural profession (AIRR=1. 332, 95% CI: 1.263 - 1.401, P = 0.004), household poverty (AIRR= 1.381, 95% CI: 1.223 - 1.431, p<0.001), infant mortality (AIRR= 1.602, 95% CI: 1.562 - 1.643, p<0.001), early marriage (AIRR= 1.313, 95% CI: 1.264 - 1.364, p<0.001), lack of knowledge of any contraceptives (AIRR= 1.263, 95% CI: 1.125 - 1.310, p = 0.003) and failure to use modern contraceptives (AIRR= 1.520, 95% CI: 1.487 - 1.611, p<0.001) were associated with high number of children ever born. However, in Morocco socioeconomic factors like residence place, women´s agricultural profession and household poverty were not significant. In this country, women´s illiteracy (AIRR=1.428, 95% CI: 1.315 - 1.551, P <0.001), lack of access to mass media (AIRR= 1.241, 95% CI: 1.108 - 1.375, p = 0.006), infant mortality (AIRR=1.222, 95%CI: 1.184 - 1.361, p<0.001), early marriage (AIRR1.481, 95% CI: 1.435 - 1.529, p<0.001), lack of knowledge of any contraceptives (AIRR1.508, 95% CI: 1.409 - 1.613, p<0.001) and failure to use modern contraceptives (AIRR1.745, 95% CI: 1.627 - 1.863, p<0.001) were associated with high fertility but with different effects than in Burundi. Conclusion: the evidence from this study suggests that interventions to accelerate the fertility transition processes in Burundi and many other countries with slow fertility transitions should be designed and implemented according to each country's local context.

Determinants of the unmet needs for information, education and communication on sexual health among single youths in Burundi.

The prevalence of HIV/AIDS among young people aged 15-24 in urban areas is at least 12 times higher among girls than boys in Burundi, while it is twice as high in Rwanda. The gap between the two countries could be narrowed if Burundi's single young people were provided with sufficient information about their sexual health through appropriate channels. The aim of this study was to examine the social and individual "determinants" of unmet needs for sexual health information, education and communication (IEC) among unmarried young boys and girls aged 15-24 in Burundi, using data from the 2016 Demographic and Health Survey (DHS). Data were analyzed at the bivariate level using cross-tabulations and chi-squared tests, and at the multivariate level using binary logistic regression methods. According to the results of the study, the 'determinants' of the phenomenon studied are, for both sexes, the size of the household, the age of the youths, their level of education, their knowledge of where to take the HIV/AIDS test and their region of residence; only in the case of boys do we find, in addition, the age of the head of the household, his level of education and the adolescents' exposure to the media; similarly, only in the case of girls do we find their economic activity and their perception of HIV/AIDS. Multisectoral IEC actions on sexual health for young people should therefore be strengthened in Burundi.

Au Burundi, en milieu urbain, la prévalence du VIH/SIDA est, chez les jeunes de 15-24 ans, au moins douze fois plus élevée chez les jeunes filles que chez les jeunes garçons, alors qu'au Rwanda elle est deux fois plus élevée. L'écart entre les deux pays serait réduit si les jeunes célibataires burundais recevaient suffisamment d'information sur leur santé sexuelle par des canaux appropriés. L'objectif de cette étude était de chercher au Burundi, chez les jeunes garçons et filles célibataires âgés de 15-24 ans, les « déterminants ¼ sociaux et individuels des Besoins Non Satisfaits (BNS) en Information, Education et Communication (IEC) en santé sexuelle à partir des données de l'Enquête Démographique et de Santé (EDS) de 2016. Ces dernières ont été analysées, au niveau bivarié, en recourant aux tableaux croisés et tests de chi-deux, et, au niveau multivarié, en recourant aux méthodes de régression logistique binaire. A en croire les résultats de l'étude, dans les deux sexes, les « déterminants ¼ du phénomène étudié sont la taille du ménage, l'âge du jeune, son niveau d'instruction, sa connaissance de l'endroit où faire le test de VIH/SIDA et sa région de résidence ; seulement, chez les garçons, on retrouve en plus l'âge du chef de ménage, son niveau d'instruction et l'exposition aux médias ; de même, seulement, chez les filles, on retrouve leur activité économique et leur perception du VIH/SIDA. Les actions multisectorielles d'IEC en santé sexuelle concernant les jeunes devraient alors être renforcées au Burundi.

Spatial distribution and predictive factors of antenatal care in Burundi: A spatial and multilevel baseline analysis for the third burundian demographic and health survey.

INTRODUCTION: The use of antenatal care by pregnant women enables them to receive good pregnancy monitoring. This monitoring includes counseling, health instructions, examinations and tests to avoid pregnancy-related complications or death during childbirth. To avoid these complications, the World Health Organization (WHO) recommends at least four antenatal visits. Therefore, this study was conducted to identify predictive factors of antenatal care (ANC) among women aged 15 to 49 years and its spatial distribution in Burundi. METHODS: We used data from the Second Burundi Demographic and Health Survey (DHS). A Spatial analysis of ANC prevalence and Mulitlevel logistic regressions of determinants factors of ANC with a medical doctor were done. The ANC prevalence was mapped by region and by province. In unsampled data points, a cluster based interpolation of ANC prevalence was done using the kernel method with an adaptive window. Predictive factors of ANC were assessed using Mulitlevel logistic regressions. The dependent variable was antenatal care with a medical doctor and the explanatory variables were place of residence, age, education level, religion, marital status of the woman, household wealth index and delivery place of the woman. Data processing and data analysis were done using using Quantum Geographic Information System (QGIS) and R software, version 3. 5. 0. RESULTS: The ANC prevalence varied from 0. 0 to 16. 2% with a median of 0. 5%. A highest predicted ANC prevalence was observed at Muyinga and Kirundo provinces' junction. Low prevalence was observed in several locations in all regions and provinces. The woman's education level and delivery place were significantly associated with antenatal care with a medical doctor. CONCLUSION: Globally, the ANC prevalence is low in Burundi. It varies across the country. There is an intra-regional or intra-provincial heterogeneity in term of ANC prevalence. Woman's education level and delivery place are significantly associated antenatal care. There is a need to consider these ANC disparities and factors in the design and strengthening of existing interventions aimed at increasing ANC visits.

'The body is difficult': reproductive navigation through sociality and corporeality in rural Burundi.

The route from family planning intentions to practices is not linear, it is contingent on different social factors including the preferences of individuals and couples, their gendered positions and bargaining power, the wider political, economic and social context, and also physical and bodily circumstances. We used qualitative data collected in rural Burundi between 2013 and 2016 to explore how these diverse factors influence reproductive navigation in a context framed by uncertainty and changing social norms. We describe representations of bodily (pre)dispositions for fertility and reproduction, such as the 'natural' capacity for birth spacing or the bodily capacity to use 'natural' (having a regular cycle) and 'modern' methods (not having negative side effects) that contribute collectively to an understanding of 'the body is difficult'. We found that despite these bodily constraints, women enact embodied agency to ensure livelihoods and social status, thus framing their reproductive intentions and practices. In the context of Burundi where corporeality is key to gendered social belonging, family planning programmes fail to respond to the needs and concerns of women and their embodied reproductive experiences.

Women's contraceptive profiles in Burundi: Knowledge, attitudes, and interactions with media and health services.

Reproductive health program managers seek information about existing and potential clients' motivations, behaviors, and barriers to services. Using sequence and cluster analysis of contraceptive calendar data from the 2016-17 Burundi Demographic and Health Survey, we identified discrete clusters characterizing patterns in women's contraceptive and pregnancy behaviors over the previous 5 years. This study pairs these clusters with data on factors typically targeted in social behavior change interventions: knowledge, attitudes, and women's interactions with media and health services, to create composite profiles of women in these clusters. Of six clusters, three are characterized by contraceptive use and three are characterized by its absence. Media exposure and attitudes regarding sex preference, wife beating, and self-efficacy largely do not explain cluster membership. Contraceptive knowledge is positively associated with two clusters (Family Builder 1 and Traditional Mother) and negatively associated with a third (Quiet Calendar). Clusters also differ in their members' fertility desires, contraceptive intentions, and interactions with health services. Two "Family Builder" clusters are both characterized by the presence (but not timing) of multiple pregnancies in their calendar histories, but differ in that women with high contraceptive knowledge, intentions to use contraception, and well-articulated family size ideals are characteristic of one cluster (Family Builder 1), and low contraceptive knowledge, no use of contraception, and vague family size preferences are characteristic of the other (Family Builder 2). These results can guide reproductive health programs as they target social and behavioral change and other interventions to the unique subpopulations they seek to serve.

Cost-Utility Analysis of Community Case Management for Malaria Control in Burundi.

BACKGROUND: The community case management (CCM) program for malaria control is a community-based strategy implemented to regulate malaria in children in Burundi. This study compared the cost and utility of implementing the CCM program combined with health facility management (HFM) versus HFM alone for malaria control in children under five in Burundi. METHODS: This study constructed a five-year Markov model with one-week cycles to estimate cost-utility and budget impact analysis (BIA). The model defined 10 health states, simulating the progression of the disease and the risk of recurrent malaria in children under five years of age. Cost data were empirically collected and presented for 2019. Incremental cost per disability-adjusted life year (DALY) averted, and a five-year budget was estimated. One-way and probabilistic sensitivity analyses (PSAs) were then performed. RESULTS: From provider and societal perspectives, combining the CCM program with HFM for malaria control in Burundi was more cost-effective than implementing HFM alone. The addition of CCM, using artesunate amodiaquine (ASAQ) as the first-line treatment, increased by US$1.70, and US$ 1.67 per DALY averted from the provider and societal perspectives, respectively. Using Artemether Lumefantrine (AL) as the first-line treatment, adding the CCM program to HFM increased by US$ 1.92, and US$ 1.87 per DALY averted from the provider and societal perspectives. At a willingness-to-pay of one GDP/capita, the CCM program remained a 100% chance of being cost-effective. In addition, implementing the program for five years requires a budget of US$ 15 800 486-19 765 117. CONCLUSION: Implementing the CCM program and HFM is value for money for malaria control in Burundi. The findings can support decision-makers in Burundi in deciding on resource allocation, especially during the program's scale up.

Public Financial Management as an Enabler for Health Financing Reform: Evidence from Free Health Care Policies Implemented in Burkina Faso, Burundi, and Niger.

In Burkina Faso, Burundi and Niger, the policy to remove user fees for primary care was carried out through significant adjustments in public financial management (PFM). The paper analyzes the PFM adjustments by stage of the budget cycle and describes their importance for health financing. The three countries shifted from input-based to program-based allocation for primary care facility compensation, allowed service providers autonomy to access and manage the funds, and established budget performance monitoring frameworks related to outputs. These PFM changes, in turn, enabled key improvements in health financing, namely, more direct funding of primary care facilities from general budget revenue, and payments to those service providers based on outputs and drawn from noncontributory entitlements. The paper draws on these experiences to provide key lessons on the PFM enabling conditions needed to expand health coverage through public financing mechanisms.

Does the Choice of Health Metric, DALY or QALY, Influence Conclusions of Health Economic Evaluation? A Case Study of Rotavirus Vaccine in Burundi.

BACKGROUND: Two metrics, quality-adjusted life-year (QALY) and disability-adjusted life-year (DALY), have been commonly used to measure health benefits associated with health interventions. This study aimed to explore the effect of the choice of health metric (DALY or QALY) on economic evaluation conclusion. METHODS: A previous published model for a cost-utility analysis (CUA) of rotavirus vaccine was adapted to estimate the QALYs gained and DALYs averted from four rotavirus vaccines: Rotarix, RotaTeq, Rotavac, and Rotasiil. The study was conducted in both Burundi provider and societal perspectives over a five-year time horizon. Disability weights (DW) were derived from the Global Burden of Disease (GBD) study. Scenario analysis was performed to evaluate the impact of age weights and source of utility weight. RESULTS: In base-case analysis, the QALYs gained ranged from 46 to 78% of the DALYs averted. The incremental cost-effectiveness ratios (ICER) per QALY gained were higher than ICER per DALY averted by 28 to 113%, leading to less favorable cost effectiveness. The QALYs gained from using 1-DW as utility weight were slightly higher than those using EQ-5D utility weight obtained from previous literature, yet less likely to alter CUA conclusions. When age-weighting was incorporated in the DALY calculation, the ICERs per DALY averted were reduced leading to more favorable cost effectiveness. CONCLUSION: In case of rotavirus diarrhea, in which mortality burden is considered larger than morbidity due to short duration of disease, although the use of DALY consistently led to more favorable cost-effective result than the use of QALY such effects were considered small and less likely to affect the EE conclusion under current CET of 1 GDP per capita.

Empirical analysis of socio-economic determinants of maternal health services utilisation in Burundi.

BACKGROUND: Timely and appropriate health care during pregnancy and childbirth are the pillars of better maternal health outcomes. However, factors such as poverty and low education levels, long distances to a health facility, and high costs of health services may present barriers to timely access and utilisation of maternal health services. Despite antenatal care (ANC), delivery and postnatal care being free at the point of use in Burundi, utilisation of these services remains low: between 2011 and 2017, only 49% of pregnant women attended at least four ANC visits. This study explores the socio-economic determinants that affect utilisation of maternal health services in Burundi. METHODS: We use data from the 2016-2017 Burundi Demographic and Health Survey (DHS) collected from 8941 women who reported a live birth in the five years that preceded the survey. We use multivariate regression analysis to explore which individual-, household-, and community-level factors determine the likelihood that women will seek ANC services from a trained health professional, the number of ANC visits they make, and the choice of assisted childbirth. RESULTS: Occupation, marital status, and wealth increase the likelihood that women will seek ANC services from a trained health professional. The likelihood that a woman consults a trained health professional for ANC services is 18 times and 16 times more for married women and women living in partnership, respectively. More educated women and those who currently live a union or partnership attend more ANC visits than non-educated women and women not in union. At higher birth orders, women tend to not attend ANC visits. The more ANC visits attended, and the wealthier women are; the more likely they are to have assisted childbirth. Women who complete four or more ANC visits are 14 times more likely to have an assisted childbirth. CONCLUSIONS: In Burundi, utilisation of maternal health services is low and is mainly driven by legal union and wealth status. To improve equitable access to maternal health services for vulnerable population groups such as those with lower wealth status and unmarried women, the government should consider certain demand stimulating policy packages targeted at these groups.

[Nailing of long bone fractures in precarious situations: focus on the Surgical Implant Generation Network (SIGN) nail]. / Enclouage des os longs en situation précaire: intérêt du clou SIGN (Surgical Implant Generation Network).

Economic development in low-income countries has led to a considerable increase in motor vehicles, in particular motorcycles. Traffic accident-related fractures are therefore increasing. The treatment of long bone fractures is, in the majority of cases, based on locked intramedullary nailing, a procedure which is rarely available in countries with poor sanitary conditions. To provide optimal treatment to these countries, the SIGN (Surgical Implant Generation Network) nail was developed in 1999 by Lewis Zirkle. It is currently used free of charge in 53 countries. In return, an international database must be completed in order to assess and develop it. In the light of our experiences in Haiti and Burundi and on the basis of a literature review, we here highlight the conceptual and technical features of SIGN nail whose implant in French-speaking countries is still limited.

The East African Community (EAC) mobile laboratory networks in Kenya, Burundi, Tanzania, Rwanda, Uganda, and South Sudan-from project implementation to outbreak response against Dengue, Ebola, COVID-19, and epidemic-prone diseases.

BACKGROUND: East Africa is home to 170 million people and prone to frequent outbreaks of viral haemorrhagic fevers and various bacterial diseases. A major challenge is that epidemics mostly happen in remote areas, where infrastructure for Biosecurity Level (BSL) 3/4 laboratory capacity is not available. As samples have to be transported from the outbreak area to the National Public Health Laboratories (NPHL) in the capitals or even flown to international reference centres, diagnosis is significantly delayed and epidemics emerge. MAIN TEXT: The East African Community (EAC), an intergovernmental body of Burundi, Rwanda, Tanzania, Kenya, Uganda, and South Sudan, received 10 million € funding from the German Development Bank (KfW) to establish BSL3/4 capacity in the region. Between 2017 and 2020, the EAC in collaboration with the Bernhard-Nocht-Institute for Tropical Medicine (Germany) and the Partner Countries' Ministries of Health and their respective NPHLs, established a regional network of nine mobile BSL3/4 laboratories. These rapidly deployable laboratories allowed the region to reduce sample turn-around-time (from days to an average of 8h) at the centre of the outbreak and rapidly respond to epidemics. In the present article, the approach for implementing such a regional project is outlined and five major aspects (including recommendations) are described: (i) the overall project coordination activities through the EAC Secretariat and the Partner States, (ii) procurement of equipment, (iii) the established laboratory setup and diagnostic panels, (iv) regional training activities and capacity building of various stakeholders and (v) completed and ongoing field missions. The latter includes an EAC/WHO field simulation exercise that was conducted on the border between Tanzania and Kenya in June 2019, the support in molecular diagnosis during the Tanzanian Dengue outbreak in 2019, the participation in the Ugandan National Ebola response activities in Kisoro district along the Uganda/DRC border in Oct/Nov 2019 and the deployments of the laboratories to assist in SARS-CoV-2 diagnostics throughout the region since early 2020. CONCLUSIONS: The established EAC mobile laboratory network allows accurate and timely diagnosis of BSL3/4 pathogens in all East African countries, important for individual patient management and to effectively contain the spread of epidemic-prone diseases.

Cost-Effectiveness Analysis of Community Case Management of Childhood Diarrhea in Burundi.

OBJECTIVE: This study aimed to evaluate the cost-effectiveness of community case management (CCM) program of childhood diarrhea by providing oral rehydration salts and zinc through community health workers in Burundi. METHODS: A cost-effectiveness analysis study using a Markov modeling approach was undertaken to assess the CCM program of diarrhea from both provider and societal perspectives. The CCM program was compared with the routine management of childhood diarrhea at health facilities. Primary data on the cost of childhood diarrhea management were collected. Both economic and health outcomes were assessed for a period of 5 years, and a discount rate of 3% was applied. One-way and probabilistic sensitivity analyses were performed. RESULTS: The CCM program was found to be both less costly and more effective resulting to a negative value of incremental cost-effectiveness ratios, indicating that the program was dominant producing cost savings. Compared with the routine treatment of diarrhea at health facilities, the CCM program would avert 2749 additional disability-adjusted life years over a period of 5 years. The economic burden was reduced of US$1 056 699 and US$2 328 531 from the provider and societal perspectives, respectively. The cost-effectiveness estimates were mostly sensitive to the discount rate and the cost of outpatient visits at health facilities. The intervention remained dominant with a 100% probability of cost savings within 10 000 simulations of the sensitivity analysis. CONCLUSIONS: Providing inexpensive diarrheal treatment (oral rehydration salts and zinc) in communities is an attractive cost-effective intervention. Evidence from this study should be used to scale up the coverage of this life- and cost-saving intervention.

Determinants of fertility differentials in Burundi: evidence from the 2016-17 Burundi demographic and health survey.

INTRODUCTION: although fertility control remains a major priority for the Burundian government and most of its partners, few studies on Burundi´s fertility determinants are available to guide interventions. To address this gap, our study aims to examine the most factors influencing fertility differentials in Burundi by using the latest Burundi demographic and health survey data. METHODS: using data from the 2016-17 Burundi demographic and health survey, one-way analysis of variance was performed to describe variations in mean number of children ever born across categories of correlate variables. Then univariable and multivariable poisson regression analyses were carried out to identify the most factors influencing fertility differentials in Burundi. RESULTS: in our sample, the total number of children ever born ranged from 0 to 15 children by women with a mean number of 2.7 children (±2.8 SD). Factors such as urban residence (aIRR 0.769, 95% CI: 0.739 - 0.782, p = 0.008), increase in the level of education of both women and husbands (aIRRs of 0.718, 95% CI: 0.643 - 0.802, P<0.001 and 0.729, 95% CI: 0.711 - 0.763, p<0.001 respectively), no history of infant mortality experience (aIRR 0.722, 95% IC: 0.710 - 0.734, p<0.001) and increase in age at first marriage or first birth (aIRRs of 0.864, 95% CI: 0.837 - 0.891, P<0.001 and 0.812, 95% CI: 0.781 - 0.845, p<0.001 respectively) are associated with a low fertility rate while factors such as residence especially in Southern region (aIRR 1.129, 95% IC: 1.077 - 1.184, p<0.001), women and husband´s agricultural profession (aIRRs of 1.521, 95% CI: 1.429 - 1.568, P<0.001 and 1.294, 95% CI: 1.211 - 1.316, p<0.001 respectively), household poverty (aIRR 1.117, 95% IC: 1.080 - 1.155, p<0.001), lack of knowledge of any contraceptive method (aIRR 1.502, 95% IC: 1.494 - 1.564, p<0.001) and non-use of modern contraceptive methods (aIRR 1.583, 95% IC: 1.562 - 1.607, p<0.001) are associated with a high fertility rate. CONCLUSION: the results of this study suggest that actions aimed at promoting education in general especially female education, improving child survival, women´s socio-economic status, agriculture mechanization and increasing number and scope of family planning services, could help reduce Burundi fertility rate.

Effective Adoption of Tablets for Psychodiagnostic Assessments in Rural Burundi: Evidence for the Usability and Validity of Mobile Technology in the Example of Differentiating Symptom Profiles in AMISOM Soldiers 1 Year After Deployment.

Research on the use of mobile technology in health sciences has identified several advantages of so-called mHealth (mobile health) applications. Tablet-supported clinical assessments are becoming more and more prominent in clinical applications, even in low-income countries. The present study used tablet computers for assessments of clinical symptom profiles in a sample of Burundian AMISOM soldiers (i.e., African Union Mission to Somalia; a mission approved by the UN). The study aimed to demonstrate the feasibility of mHealth-supported assessments in field research in Burundi. The study was conducted in a resource-poor setting, in which tablet computers are predestined to gather data in an efficient and reliable manner. The overall goal was to prove the validity of the obtained data as well as the feasibility of the chosen study setting. Four hundred sixty-three soldiers of the AMISOM forces were investigated after return from a 1-year military mission in Somalia. Symptoms of posttraumatic stress disorder (PTSD) and depression were assessed. The used data-driven approach based on a latent profile analysis revealed the following four distinct groups, which are based on the soldiers' PTSD and depression symptom profiles: Class 1: moderate PTSD, Class 2: moderate depression, Class 3: low overall symptoms, and Class 4: high overall symptoms. Overall, the four identified classes of soldiers differed significantly in their PTSD and depression scores. The study clearly demonstrates that tablet-supported assessments can provide a useful application of mobile technology in large-scale studies, especially in resource-poor settings. Based on the data collected for the study at hand, it was possible to differentiate different sub-groups of soldiers with distinct symptom profiles, proving the statistical validity of the gathered data. Finally, advantages and challenges for the application of mobile technology in a resource-poor setting are outlined and discussed.

Socioeconomic inequalities in lifestyle risk factors across low- and middle-income countries.

BACKGROUND: The heavy and ever rising burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) warrants interventions to reduce their underlying risk factors, which are often linked to lifestyles. To effectively supplement nationwide policies with targeted interventions, it is important to know how these risk factors are distributed across socioeconomic segments of populations in LMICs. This study quantifies the prevalence and socioeconomic inequalities in lifestyle risk factors in LMICs, to identify policy priorities conducive to the Sustainable Development Goal of a one third reduction in deaths from NCDs by 2030. METHODS: Data from 1,278,624 adult respondents to Demographic & Health Surveys across 22 LMICs between 2013 and 2018 are used to estimate crude prevalence rates and socioeconomic inequalities in tobacco use, overweight, harmful alcohol use and the clustering of these three in a household. Inequalities are measured by a concentration index and correlated with the percentage of GDP spent on health. We estimate a multilevel model to examine associations of individual characteristics with the different lifestyle risk factors. RESULTS: The prevalence of tobacco use among men ranges from 59.6% (Armenia) to 6.6% (Nigeria). The highest level of overweight among women is 83.7% (Egypt) while this is less than 12% in Burundi, Chad and Timor-Leste. 82.5% of women in Burundi report that their partner is "often or sometimes drunk" compared to 1.3% in Gambia. Tobacco use is concentrated among the poor, except for the low share of men smoking in Nigeria. Overweight, however, is concentrated among the better off, especially in Tanzania and Zimbabwe (Erreygers Index (EI) 0.227 and 0.232). Harmful alcohol use is more concentrated among the better off in Nigeria (EI 0.127), while Chad, Rwanda and Togo show an unequal pro-poor distribution (EI respectively - 0.147, - 0.210, - 0.266). Cambodia exhibits the largest socioeconomic inequality in unhealthy household behaviour (EI - 0.253). The multilevel analyses confirm that in LMICs, tobacco and alcohol use are largely concentrated among the poor, while overweight is concentrated among the better-off. The associations between the share of GDP spent on health and the socioeconomical distribution of lifestyle factors are multidirectional. CONCLUSIONS: This study emphasizes the importance of lifestyle risk factors in LMICs and the socioeconomic variation therein. Given the different socioeconomic patterns in lifestyle risk factors - overweight patters in LMICs differ considerably from those in high income countries- tailored interventions towards specific high-risk populations are warranted to supplement nationwide policies.

Poor coverage and quality for poor women: Inequalities in quality antenatal care in nine East African countries.

The use of quality antenatal care (ANC) improves maternal and newborn health outcomes. Ensuring equity in access to quality maternal health services is a priority agenda in low- and middle-income countries. This study aimed to assess inequalities in the use of quality ANC in nine East African countries using the most recent Demographic and Health Surveys. We used two outcome variables to examine ANC service adequacy: four or more ANC contacts and quality ANC. We defined quality ANC as having six of the recommended ANC components during follow-up: blood pressure measurement, urine sample test, blood sample test, provision of iron supplements, drug for intestinal parasite and tetanus toxoid injections. We used the concentration index (CCI) to examine inequalities within and across countries. We fitted a multilevel regression model to assess the predictors of inequalities in the contact and content of ANC. This study included 87 068 women; among those 54.4% (n = 47 387) had four or more ANC contacts, but only 21% (n = 15 759) reported receiving all six services. The coverage of four or more ANC and receipt of all six services was pro-rich within and across all countries. The highest inequality in four or more ANC contacts was in Ethiopia with a CCI of 0.209, while women in Burundi had the highest inequality in coverage of all six services (CCI: 0.318). Higher education levels and media exposure were predictors of service uptake, while women who had unintended pregnancies were less likely to make four or more ANC contacts and receive six services. Interventions to improve access to quality ANC require rethinking the service delivery mechanisms in all countries. Moreover, ensuring equity in access to quality ANC requires tailoring service delivery modalities to address the social determinants of service uptake.

Economic burden of childhood diarrhea in Burundi.

BACKGROUND: In 2016, diarrhea killed around 7 children aged under 5 years per 1000 live births in Burundi. The objective of this study was to estimate the economic burden associated with diarrhea in Burundi and to examine factors affecting the cost to provide economic evidence useful for the policymaking about clinical management of diarrhea. METHODS: The study was designed as a prospective cost-of-illness study using an incidence-based approach from the societal perspective. The study included patients aged under 5 years with acute non-bloody diarrhea who visited Buyenzi health center and Prince Regent Charles hospital from November to December 2019. Data were collected through interviews with patients' caregivers and review of patients' medical and financial records. Multiple linear regression was performed to identify factors affecting cost, and a cost model was used to generate predictions of various clinical and care management costs. All costs were converted into international dollars for the year 2019. RESULTS: One hundred thirty-eight patients with an average age of 14.45 months were included in this study. Twenty-one percent of the total patients included were admitted. The average total cost per episode of diarrhea was Int$109.01. Outpatient visit and hospitalization costs per episode of diarrhea were Int$59.87 and Int$292, respectively. The costs were significantly affected by the health facility type, patient type, health insurance scheme, complications with dehydration, and duration of the episode before consultation. Our model indicates that the prevention of one case of dehydration results in savings of Int$16.81, accounting for approximately 11 times of the primary treatment cost of one case of diarrhea in the community-based management program for diarrhea in Burundi. CONCLUSION: Diarrhea is associated with a substantial economic burden to society. Evidence from this study provides useful information to support health interventions aimed at prevention of diarrhea and dehydration related to diarrhea in Burundi. Appropriate and timely care provided to patients with diarrhea in their communities and primary health centers can significantly reduce the economic burden of diarrhea. Implementing a health policy to provide inexpensive treatment to prevent dehydration can save significant amount of health expenditure.

Antenatal care and skilled birth in the fragile and conflict-affected situation of Burundi.

Burundi is a fragile and conflict-affected state characterized by persistent conflict and political violence. Amid this conflict, Burundi has one of the highest maternal mortality rates globally-548 per 100,000 births as of 2017, such deaths could be prevented with antenatal care (ANC). This cross-sectional study aimed to examine the association between conflict and ANC and skilled birth attendant (SBA) utilization. Logistic regression analysis was conducted using the 2016-2017 Burundi Demographic and Health Survey (n = 8581), as well as a Near Analysis Geographic Information System exploration. Results show that women in extremely high conflict regions were less likely to have four antenatal visits (odds ratio [OR] = 0.79, p < 0.05). However, they were more likely to use a SBA (OR = 2.31, p < 0.001) and to deliver in a hospital (OR = 1.69, p < 0.001). As well, gender equality, education, and watching television were correlated with an increased likelihood of utilization. In contrast, unwanted pregnancies and increased parity were correlated with decreased use. Moreover, with renewed violence erupting in 2015, uptake of care has likely further stagnated or declined. If Sustainable Development Goal 3.1's objective of reducing maternal mortality globally is to be achieved, women's access to maternal healthcare services in conflicted-affected areas such as Burundi must be improved.