Vaccination coverage in rural Burkina Faso under the effects of COVID-19: evidence from a panel study in eight districts.

BACKGROUND: Improving infant immunization completion and promoting equitable vaccination coverage are crucial to reducing global under-5 childhood mortality. Although there have been hypotheses that the impact of the COVID-19 pandemic would decrease the delivery of health services and immunization campaigns in low- and middle-income countries, the available evidence is still inconclusive. We conducted a study in rural Burkina Faso to assess changes in vaccination coverage during the pandemic. A secondary objective was to examine long-term trends in vaccination coverage throughout 2010-2021. METHODS: Using a quasi-experimental approach, we conducted three rounds of surveys (2019, 2020, 2021) in rural Burkina Faso that we pooled with two previous rounds of demographic and household surveys (2010, 2015) to assess trends in vaccination coverage. The study population comprised infants aged 0-13 months from a sample of 325 households randomly selected in eight districts (n = 736). We assessed vaccination coverage by directly observing the infants' vaccination booklet. Effects of the pandemic on infant vaccination completion were analyzed using multi-level logistic regression models with random intercepts at the household and district levels. RESULTS: A total of 736 child-year observations were included in the analysis. The proportion of children with age-appropriate complete vaccination was 69.76% in 2010, 55.38% in 2015, 50.47% in 2019-2020, and 64.75% in 2021. Analyses assessing changes in age-appropriate full-vaccination coverage before and during the pandemic show a significant increase (OR: 1.8, 95% CI: 1.14-2.85). Our models also confirmed the presence of heterogeneity in full vaccination between health administrative districts. The pandemic could have increased inequities in infant vaccination completion between these districts. The analyses suggest no disruption in age-appropriate full vaccination due to COVID-19. Our findings from our sensitivity analyses to examine trends since 2010 did not show any steady trends. CONCLUSION: Our findings in Burkina Faso do not support the predicted detrimental effects of COVID-19 on the immunization schedule for infants in low- and middle-income countries. Analyses comparing 2019 and 2021 show an improvement in age-appropriate full vaccination. Regardless of achieving and sustaining vaccination coverage levels in Burkina Faso, this should remain a priority for health systems and political agendas.

Factors Associated With Human IgG Antibody Response to Anopheles albimanus Salivary Gland Extract, Artibonite Department, Haiti, 2017.

Serological data can provide estimates of human exposure to both malaria vector and parasite based on antibody responses. A multiplex bead-based assay was developed to simultaneously detect IgG to Anopheles albimanus salivary gland extract (SGE) and 23 Plasmodium falciparum antigens among 4185 participants enrolled in Artibonite department, Haiti in 2017. Logistic regression adjusted for participant- and site-level covariates and found children under 5 years and 6-15 years old had 3.7- and 5.4-fold increase in odds, respectively, of high anti-SGE IgG compared to participants >15 years. Seropositivity to P. falciparum CSP, Rh2_2030, and SEA-1 antigens was significantly associated with high IgG response against SGE, and participant enrolment at elevations under 200 m was associated with higher anti-SGE IgG levels. The ability to approximate population exposure to malaria vectors through SGE serology data is very dependent by age categories, and SGE antigens can be easily integrated into a multiplex serological assay.

The Immediate Effects of a Combined Mass Drug Administration and Indoor Residual Spraying Campaign to Accelerate Progress Toward Malaria Elimination in Grande-Anse, Haiti.

BACKGROUND: Haiti is planning targeted interventions to accelerate progress toward malaria elimination. In the most affected department (Grande-Anse), a combined mass drug administration (MDA) and indoor residual spraying (IRS) campaign was launched in October 2018. This study assessed the intervention's effectiveness in reducing Plasmodium falciparum prevalence. METHODS: An ecological quasi-experimental study was designed, using a pretest and posttest with a nonrandomized control group. Surveys were conducted in November 2017 in a panel of easy access groups (25 schools and 16 clinics) and were repeated 2-6 weeks after the campaign, in November 2018. Single-dose sulfadoxine-pyrimethamine and primaquine was used for MDA, and pirimiphos-methyl as insecticide for IRS. RESULTS: A total of 10 006 participants were recruited. Fifty-two percent of the population in the intervention area reported having received MDA. Prevalence diminished between 2017 and 2018 in both areas, but the reduction was significantly larger in the intervention area (ratio of adjusted risk ratios, 0.32 [95% confidence interval, .104-.998]). CONCLUSIONS: Despite a moderate coverage, the campaign was effective in reducing P. falciparum prevalence immediately after 1 round. Targeted MDA plus IRS is useful in preelimination settings to rapidly decrease the parasite reservoir, an encouraging step to accelerate progress toward malaria elimination.

Using experience to create evidence: a mixed methods process evaluation of the new free family planning policy in Burkina Faso.

BACKGROUND: In 2019, Burkina Faso was one of the first countries in Sub-Saharan Africa to introduce a free family planning (FP) policy. This process evaluation aims to identify obstacles and facilitators to its implementation, examine its coverage in the targeted population after six months, and investigate its influence on the perceived quality of FP services. METHODS: This process evaluation was conducted from November 2019 through March 2020 in the two regions of Burkina Faso where the new policy was introduced as a pilot. Mixed methods were used with a convergent design. Semi-directed interviews were conducted with the Ministry of Health (n = 3), healthcare workers (n = 10), and women aged 15-49 years (n = 10). Surveys were also administered to the female members of 696 households randomly selected from four health districts (n = 901). RESULTS: Implementation obstacles include insufficient communication, shortages of consumables and contraceptives, and delays in reimbursement from the government. The main facilitators were previous experience with free healthcare policies, good acceptability in the population, and support from local associations. Six months after its introduction, only 50% of the surveyed participants knew about the free FP policy. Higher education level, being sexually active or in a relationship, having recently seen a healthcare professional, and possession of a radio significantly increased the odds of knowing. Of the participants, 39% continued paying for FP services despite the new policy, mainly because of stock shortages forcing them to buy their contraceptive products elsewhere. Increased waiting time and shorter consultations were also reported. CONCLUSION: Six months after its introduction, the free FP policy still has gaps in its implementation, as women continue to spend money for FP services and have little knowledge of the policy, particularly in the Cascades region. While its use is reportedly increasing, addressing implementation issues could further improve women's access to contraception.

Burkina Faso is one of the first countries in sub-Saharan Africa to remove user fees for family planning services. Introduced as a pilot in June 2019, this policy covers the main costs, including the contraceptives, for all women of reproductive age (15­49 years old). We conducted a study to find out how the implementation of this new policy was going. In particular, we wanted to know what might be limiting or facilitating the successful implementation of the policy in a rural community. Through interviews with health staff and women, we found that about half of the women did not even know that family planning was now free, even though it had been free for more than six months. In addition, there were problems in the supply chain, which meant that contraceptive methods may have become free, but they were no longer available. On the other hand, the new policy has been generally well received by the public: previous similar initiatives seem to have facilitated implementation, as have awareness campaigns conducted by non-governmental organizations. With this information, the new policy can be improved to further enhance women's access to contraceptive methods in rural Burkina Faso.

Women's decision-making power in a context of free reproductive healthcare and family planning in rural Burkina Faso.

BACKGROUND: In 2016, the national user fee exemption policy for women and children under five was introduced in Burkina Faso. It covers most reproductive healthcare services for women including prenatal care, delivery, and postnatal care. In subsequent years, the policy was gradually extended to include family planning. While studies have shown that user fee abolition policies increase visits to health centers and improve access to reproductive healthcare and family planning, there are also indications that other barriers remain, notably women's lack of decision-making power. The objective of the study is to investigate women's decision-making power regarding access to reproductive health and family planning in a context of free healthcare in rural Burkina Faso. METHODS: A descriptive qualitative study was carried out in rural areas of the Cascades and Center-West regions. Qualitative data were collected using individual semi-structured interviews (n = 20 participants) and focus groups (n = 15 participants) with Burkinabe women of childbearing age, their husbands, and key informants in the community. Data was analyzed using thematic analysis. RESULTS: A conceptual framework describing women's participation in the decision-making process was built from the analysis. Results show that the user fee exemption policy contributes to improving access to reproductive care and family planning by facilitating the negotiation processes between women and their families within households. However, social norms and gender inequalities still limit women's decision-making power. CONCLUSION: In light of these results, courses of action that go beyond the user fee exemption policy should be considered to improve women's decision-making power in matters of health, particularly with regard to family planning. Interventions that involve men and community members may be necessary to challenge the social norms, which act as determinants of women's health and empowerment.

Conventional and High-Sensitivity Malaria Rapid Diagnostic Test Performance in 2 Transmission Settings: Haiti 2017.

Accurate malaria diagnosis is foundational for control and elimination, and Haiti relies on histidine-rich protein 2 (HRP2)-based rapid diagnostic tests (RDTs) identifying Plasmodium falciparum in clinical and community settings. In 2017, 1 household and 2 easy-access group surveys tested all participants (N = 32 506) by conventional and high-sensitivity RDTs. A subset of blood samples (n = 1154) was laboratory tested for HRP2 by bead-based immunoassay and for P. falciparum 18S rDNA by photo-induced electron transfer polymerase chain reaction. Both RDT types detected low concentrations of HRP2 with sensitivity estimates between 2.6 ng/mL and 14.6 ng/mL. Compared to the predicate HRP2 laboratory assay, RDT sensitivity ranged from 86.3% to 96.0% between tests and settings, and specificity from 90.0% to 99.6%. In the household survey, the high-sensitivity RDT provided a significantly higher number of positive tests, but this represented a very small proportion (<0.2%) of all participants. These data show that a high-sensitivity RDT may have limited utility in a malaria elimination setting like Haiti.

Nationwide Monitoring for Plasmodium falciparum Drug-Resistance Alleles to Chloroquine, Sulfadoxine, and Pyrimethamine, Haiti, 2016-2017.

Haiti is striving for zero local malaria transmission by the year 2025. Chloroquine remains the first-line treatment, and sulfadoxine/pyrimethamine (SP) has been used for mass drug-administration pilot programs. In March 2016, nationwide molecular surveillance was initiated to assess molecular resistance signatures for chloroquine and SP. For 778 samples collected through December 2017, we used Sanger sequencing to investigate putative resistance markers to chloroquine (Pfcrt codons 72, 74, 75, and 76), sulfadoxine (Pfdhps codons 436, 437, 540, 581, 613), and pyrimethamine (Pfdhfr codons 50, 51, 59, 108, 164). No parasites harbored Pfcrt point mutations. Prevalence of the Pfdhfr S108N single mutation was 47%, and we found the triple mutant Pfdhfr haplotype (108N, 51I, and 59R) in a single isolate. We observed no Pfdhps variants except in 1 isolate (A437G mutation). These data confirm the lack of highly resistant chloroquine and SP alleles in Haiti and support the continued use of chloroquine and SP.

Programmatic options for monitoring malaria in elimination settings: easy access group surveys to investigate Plasmodium falciparum epidemiology in two regions with differing endemicity in Haiti.

BACKGROUND: As in most eliminating countries, malaria transmission is highly focal in Haiti. More granular information, including identifying asymptomatic infections, is needed to inform programmatic efforts, monitor intervention effectiveness, and identify remaining foci. Easy access group (EAG) surveys can supplement routine surveillance with more granular information on malaria in a programmatically tractable way. This study assessed how and which type of venue for EAG surveys can improve understanding malaria epidemiology in two regions with different transmission profiles. METHODS: EAG surveys were conducted within the departments of Artibonite and Grand'Anse (Haiti), in regions with different levels of transmission intensity. Surveys were conducted in three venue types: primary schools, health facilities, and churches. The sampling approach varied accordingly. Individuals present at the venues at the time of the survey were eligible whether they presented malaria symptoms or not. The participants completed a questionnaire and were tested for Plasmodium falciparum by a highly sensitive rapid diagnostic test (hsRDT). Factors associated with hsRDT positivity were assessed by negative binomial random-effects regression models. RESULTS: Overall, 11,029 individuals were sampled across 39 venues in Artibonite and 41 in Grand'Anse. The targeted sample size per venue type (2100 in Artibonite and 2500 in Grand'Anse) was reached except for the churches in Artibonite, where some attendees left the venue before they could be approached or enrolled. Refusal rate and drop-out rate were < 1%. In total, 50/6003 (0.8%) and 355/5026 (7.1%) sampled individuals were hsRDT positive in Artibonite and Grand'Anse, respectively. Over half of all infections in both regions were identified at health facilities. Being male and having a current or reported fever in the previous 2 weeks were consistently identified with increased odds of being hsRDT positive. CONCLUSIONS: Surveys in churches were problematic because of logistical and recruitment issues. However, EAG surveys in health facilities and primary schools provided granular information about malaria burden within two departments in Haiti. The EAG surveys were able to identify residual foci of transmission that were missed by recent national surveys. Non-care seeking and/or asymptomatic malaria infections can be identified in this alternative surveillance tool, facilitating data-driven decision-making for improved targeting of interventions.

Management of uncomplicated malaria among children under five years at public and private sector facilities in Mali.

BACKGROUND: Prompt and effective malaria diagnosis and treatment is a cornerstone of malaria control. Case management guidelines recommend confirmatory testing of suspected malaria cases, then prescription of specific drugs for uncomplicated malaria and for severe malaria. This study aims to describe case management practices for children aged 1-59 months seeking treatment with current or recent fever from public and private, rural and urban health providers in Mali. METHODS: Data were collected at sites in Sikasso Region and Bamako. Health workers recorded key information from the consultation including malaria diagnostic testing and result, their final diagnosis, and all drugs prescribed. Children with signs of severe diseases were ineligible. Consultations were not independently observed. Appropriate case management was defined as both 1) tested for malaria using rapid diagnostic test or microscopy, and 2) receiving artemisinin combination therapy (ACT) and no other antimalarials if test-positive, or receiving no antimalarials if test-negative. RESULTS: Of 1602 participating children, 23.7% were appropriately managed, ranging from 5.3% at public rural facilities to 48.4% at community health worker sites. The most common reason for 'inappropriate' management was lack of malaria diagnostic testing (50.4% of children). Among children with confirmed malaria, 50.8% received a non-ACT antimalarial (commonly artesunate injection or artemether), either alone or in combination with ACT. Of 215 test-negative children, 44.2% received an antimalarial drug, most commonly ACT. Prescription of multiple drugs was common: 21.7% of all children received more than one type of antimalarial, while 51.9% received an antibiotic and antimalarial. Inappropriate case management increased in children with increasing axillary temperatures and those seeking care over weekends. CONCLUSIONS: Multiple limitations in management of febrile children under five were identified, including inconsistent use of confirmatory testing and apparent use of severe malaria drugs for uncomplicated malaria. While we cannot confirm the reasons for these shortcomings, there is a need to address the high use of non-ACT antimalarials in this context; to minimize potential for drug resistance, reduce unnecessary expense, and preserve life-saving treatment for severe malaria cases. These findings highlight the challenge of managing febrile illness in young children in a high transmission setting.

User fee policies and women's empowerment: a systematic scoping review.

BACKGROUND: Over the past decade, an increasing number of low- and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage. Despite the large number of studies (including meta-analyses and systematic reviews) that have shown this strategy's positive effects impact on health-related indicators, the repercussions on women's empowerment or gender equality has been overlooked in the literature. The aim of this study is to systematically review the evidence on the association between user fee policies in low- and middle-income countries and women's empowerment. METHODS: A systematic scoping review was conducted. Two reviewers conducted the database search in six health-focused databases (Pubmed, CAB Abstracts, Embase, Medline, Global Health, EBM Reviews) using English key words. The database search was conducted on February 20, 2020, with no publication date limitation. Qualitative analysis of the included articles was conducted using a thematic analysis approach. The material was organized based on the Gender at Work analytical framework. RESULTS: Out of the 206 initial records, nine articles were included in the review. The study settings include three low-income countries (Burkina Faso, Mali, Sierra Leone) and two lower-middle countries (Kenya, India). Four of them examine a direct association between user fee policies and women's empowerment, while the others address this issue indirectly -mostly by examining gender equality or women's decision-making in the context of free healthcare. The evidence suggests that user fee removal contributes to improving women's capability to make health decisions through different mechanisms, but that the impact is limited. In the context of free healthcare, women's healthcare decision-making power remains undermined because of social norms that are prevalent in the household, the community and the healthcare centers. In addition, women continue to endure limited access to and control over resources (mainly education, information and economic resources). CONCLUSION: User fee removal policies alone are not enough to improve women's healthcare decision-making power. Comprehensive and multi-sectoral approaches are needed to bring sustainable change regarding women's empowerment. A focus on "gender equitable access to healthcare" is needed to reconcile women's empowerment and the efforts to achieve universal health coverage.

Measuring malaria diagnosis and treatment coverage in population-based surveys: a recall validation study in Mali among caregivers of febrile children under 5 years.

BACKGROUND: Nationally-representative household surveys are the standard approach to monitor access to and treatment with artemisinin-based combination therapy (ACT) among children under 5 years (U5), however these indicators are dependent on caregivers' recall of the treatment received. METHODS: A prospective case-control study was performed in Mali to validate caregivers' recall of treatment received by U5s when seeking care for fever from rural and urban public health facilities, community health workers and urban private facilities. Clinician-recorded consultation details were the gold standard. Consenting caregivers were followed-up for interview at home within 2 weeks using standard questions from Demographic and Health Surveys and Malaria Indicator Surveys. RESULTS: Among 1602 caregivers, sensitivity of recalling that the child received a finger/heel prick was 91.5%, with specificity 85.7%. Caregivers' recall of a positive malaria test result had sensitivity 96.2% with specificity 59.7%. Irrespective of diagnostic test result, the sensitivity and specificity of caregivers' recalling a malaria diagnosis made by the health worker were 74.3% and 74.9%, respectively. Caregivers' recall of ACT being given had sensitivity of 43.2% and specificity 90.2%, while recall that any anti-malarial was given had sensitivity 59.0% and specificity 82.7%. Correcting caregivers' response of treatment received using a combination of a visual aid with photographs of common drugs for fever, prescription documents and retained packaging changed ACT recall sensitivity and specificity to 91.5% and 71.1%, respectively. CONCLUSIONS: These findings indicate that caregivers' responses during household surveys are valid when assessing if a child received a finger/heel prick during a consultation in the previous 2 weeks, and if the malaria test result was positive. Recall of ACT treatment received by U5s was poor when based on interview response only, but was substantially improved when incorporating visual aids, prescriptions and drug packaging review.

High-throughput malaria serosurveillance using a one-step multiplex bead assay.

BACKGROUND: Serological data indicating the presence and level of antibodies against infectious disease antigens provides indicators of exposure and transmission patterns in a population. Laboratory testing for large-scale serosurveys is often hindered by time-consuming immunoassays that employ multiple tandem steps. Some nations have recently begun using malaria serosurveillance data to make inferences about the malaria exposure in their populations, and serosurveys have grown increasingly larger as more accurate estimates are desired. Presented here is a novel approach of antibody detection using bead-based immunoassay that involves incubating all assay reagents concurrently overnight. RESULTS: A serosurvey in was performed in Haiti in early 2017 with both sera (n = 712) and dried blood spots (DBS, n = 796) collected for the same participants. The Luminex® multiplex bead-based assay (MBA) was used to detect total IgG against 8 malaria antigens: PfMSP1, PvMSP1, PmMSP1, PfCSP, PfAMA1, PfLSA1, PfGLURP-R0, PfHRP2. All sera and DBS samples were assayed by MBA using a standard immunoassay protocol with multiple steps, as well a protocol where sample and all reagents were incubated together overnight-termed here the OneStep assay. When compared to a standard multi-step assay, this OneStep assay amplified the assay signal for IgG detection for all 8 malaria antigens. The greatest increases in assay signal were seen at the low- and mid-range IgG titers and were indicative of an enhancement in the analyte detection, not simply an increase in the background signal of the assay. Seroprevalence estimates were generally similar for this sample Haitian population for all antigens regardless of serum or DBS sample type or assay protocol used. CONCLUSIONS: When using the MBA for IgG detection, overnight incubation for the test sample and all assay reagents greatly minimized hands-on time for laboratory staff. Enhanced IgG signal was observed with the OneStep assay for all 8 malaria antigens employed in this study, and seroprevalence estimates for this sample population were similar regardless of assay protocol used. This overnight incubation protocol has the potential to be deployed for large-scale malaria serosurveys for the high-throughput and timely collection of antibody data, particularly for malaria seroprevalence estimates.

"Wherever doctors cannot reach, the sunshine can": overcoming potential barriers to malaria elimination interventions in Haiti.

BACKGROUND: Haiti and the Dominican Republic, the only two Caribbean countries with endemic malaria transmission, are committed to eliminating malaria. With a Plasmodium falciparum prevalence under 1% and a highly focal transmission, the efforts towards elimination in Haiti will include several community-based interventions that must be tailored to the local sociocultural context to increase their uptake. However, little is known about local community perceptions regarding malaria and the planned elimination interventions. The aim of this study is to develop a robust understanding of how to tailor, implement and promote malaria elimination strategies in Haiti. METHODS: A cross-sectional qualitative study was conducted December 2015-August 2016 in Grande-Anse and the North Department in Haiti. Data collection included key informant interviews (n = 51), in-depth interviews (n = 15) and focus group discussions (n = 14) with health workers, traditional healers, teachers, priests or pastors, informal community leaders, public officials, and community members. Following a grounded theory approach, transcripts were coded and analysed using content analysis. Coded text was sorted by the types of interventions under consideration by the malaria elimination programme. RESULTS: The level of knowledge about malaria was low. Many participants noted community beliefs about malaria being caused by magical phenomena in addition to vector-borne transmission. Participants described malaria as a problem rooted in the environment, with vector control the most noted method of prevention. Though participants noted malaria a severe disease, it ranked lower than other health problems perceived as more acute. Access barriers to healthcare were described including a lack of bed nets. Some distrust about pills, tests, and foreigners in general was expressed, and in few cases linked to previous experience with malaria campaigns under dictatorial regimes. CONCLUSIONS: There are several potential barriers and opportunities to implement community-based malaria elimination interventions in rural Haiti. Elimination efforts should include the collaboration of voodoo priests and other traditional healers, be coupled with solutions to wider community concerns or other health interventions, and learn from previous or similar programmes, such as the campaign to eliminate lymphatic filariasis. It is essential to engage with communities and gain their trust to successfully implement targeted aggressive elimination activities.

Integrated primary health care in low- and middle-income countries: a double challenge.

BACKGROUND: The lack of primary healthcare integration has been identified as one of the main limits to programs' efficacy in low- and middle-income countries. This is especially relevant to the Millennium Development Goals, whose health objectives were not attained in many countries at their term in 2015. While global health scholars and decision-makers are unanimous in calling for integration, the objective here is to go further and contribute to its promotion by presenting two of the most important challenges to be met for its achievement: 1) developing a "crosswise approach" to implementation that is operational and effective; and 2) creating synergy between national programs and interventions driven by non-State actors. MAIN BODY: The argument for urgently addressing this double challenge is illustrated by drawing on observations made and lessons learned during a four-year research project (2011-2014) evaluating the effects of interventions against malaria in Burkina Faso. The way interventions were framed was mostly vertical, leaving little room for local adaptation. In addition, many non-governmental organizations intervened and contributed to a fragmented and heteronomous health governance system. Important ethical issues stem from how interventions against malaria were shaped and implemented in Burkina Faso. To further explore this issue, a scoping literature review was conducted in August 2016 on the theme of integrated primary healthcare. It revealed that no clear definition of the concept has been advanced or endorsed thus far. We call for caution in conceptualizing it as a simple juxtaposition of different tasks or missions at the primary care level. It is time to go beyond the debate around selective versus comprehensive approaches or fragmentation versus cohesion. Integration should be thought of as a process to reconcile these tensions. CONCLUSIONS: In the context that characterizes many low- and middle-income countries today, better aid coordination and public health systems strengthening, as promoted by multisectoral approaches, might be among the best options to sustainably and ethically integrate primary healthcare interventions.

Utilization of community health workers for malaria treatment: results from a three-year panel study in the districts of Kaya and Zorgho, Burkina Faso.

BACKGROUND: Malaria is holo-endemic in Burkina Faso and causes approximately 40,000 deaths every year. In 2010, health authorities scaled up community case management of malaria with artemisinin-based combination therapy. Previous trials and pilot project evaluations have shown that this strategy may be feasible, acceptable, and effective under controlled implementation conditions. However, little is known about its effectiveness or feasibility/acceptability under real-world conditions of implementation at national scale. METHODS: A panel study was conducted in two health districts of Burkina Faso, Kaya and Zorgho. Three rounds of surveys were conducted during the peak malaria-transmission season (in August 2011, 2012 and 2013) in a panel of 2,232 randomly selected households. All sickness episodes in children under five and associated health-seeking practices were documented. Community health worker (CHW) treatment coverage was evaluated and the determinants of consulting a CHW were analysed using multi-level logistic regression. RESULTS: In urban areas, less than 1% of sick children consulted a CHW, compared to 1%-9% in rural areas. Gaps remained between intentions and actual practices in treatment-seeking behaviour. In 2013, the most frequent reasons for not consulting the CHW were: the fact of not knowing him/her (78% in urban areas; 33% in rural areas); preferring the health centre (23% and 45%, respectively); and drug stock-outs (2% and 12%, respectively). The odds of visiting a CHW in rural areas significantly increased with the distance to the nearest health centre and if the household had been visited by a CHW during the previous three months. CONCLUSIONS: This study shows that CHWs are rarely used in Burkina Faso to treat malaria in children. Issues of implementation fidelity, a lack of adaptation to the local context and problems of acceptability/feasibility might have undermined the effectiveness of community case management of malaria. While some suggest extending this strategy in urban areas, total absence of CHW services uptake in these areas suggest that caution is required. Even in rural areas, treatment coverage by CHWs was considerably less than that reported by previous trials and pilot projects. This study confirms the necessity of evaluating public health interventions under real-world conditions of implementation.

Insecticide-treated nets ownership and utilization among under-five children following the 2010 mass distribution in Burkina Faso.

BACKGROUND: Periodic mass distributions contribute significantly to universal access to insecticide-treated nets (ITNs). However, due to the limited number of nets distributed, needs remain unsatisfied, particularly in large households. METHODS: This study was conducted in Kaya health district following the 2010 mass distribution of ITNs in Burkina Faso. Data were collected on the socio-economic and geo-spatial characteristics and ITN possession and utilization levels of 2,004 households. The study explored: 1) ITN access, in terms of intra-household saturation with ITNs (households with at least one ITN for every two members) correctly installed and in very good physical condition; and 2) factors influencing the decision to place under-five children under a net. Particular attention was given to vector control activities undertaken by mothers. RESULTS: Of the 2,004 households, 90% possessed at least one ITN. However, intra-household saturation with ITNs was below 60% in small households and below 20% in large ones (>6 members). Crude proportion ratios comparing possession and levels of intra-household saturation with ITNs varied between 1.5 (small households) and 7.8 (large households). The proportions of households with ITNs for every two members that were correctly hung or in very good physical condition ranged from 0% to 6.5% in large households and 27.8% to 40.7% in small ones. ITN use to protect under-five children was lower in large households; it was significantly higher when there was at least one ITN for every two members. In large households, it was significantly higher when a child had experienced an episode of any illness in the previous two weeks and when the mother had taken actions to control vector proliferation. In small households, ITN use was significantly higher in families with agricultural land and children aged 12-23 months. CONCLUSION: Ownership rates were high, but real access to bed nets remained limited. The allocation process disadvantages large families. Real access to bed nets implies they are available, properly installed, and in good condition. More post-campaign awareness-raising activities targeting preventive practices in households could foster more effective ITN use.

Health Planning in Times of COVID-19 in Burkina Faso: The Role of Its National Strategic Pandemic Management Committee.

CONTEXT: Presenting the COVID-19 crisis as a pandemic misleadingly implies a certain homogeneity between the regions of the Globe in terms of their burden and reactions. However, from the outset of the crisis, countries presented different epidemiological realities and sometimes adopted divergent, even opposing measures. Curiously, the heterogeneity of responses persisted as scientific evidence accumulated about COVID-19 and the strategies for dealing with it. CASE STUDY: This commentary aims to recount the specific experience of Burkina Faso, and how it reoriented its initial biomedical response into a multisectoral strategy. Burkina Faso set up a committee specifically to examine the effects not only of the pandemic, but also of the control measures. This committee was mandated to decompartmentalize the lens through which the COVID-19 was dealt with. It entered into dialogue with a level of stakeholders often overlooked during national health crisis: communities. As a member of this "National Committee for Crisis Management of the Pandemic", one of the co-authors contributed to its orientations and has witnessed first-hand some of the challenges it faced. RECOMMENDATIONS: This experience suggests that the project of extricating the field of public health from medicine is advancing in Burkina Faso. In order to manage future crises more effectively and across different sectors, there is an urgent need to establish state structures and to strengthen public health systems. States need coordination units that have the legitimacy, authority and resources required to mobilize a variety of actors at the community, national and international levels.

Environmental measures to improve pedestrian safety in low- and middle-income countries: a scoping review.

OBJECTIVES: This scoping study aims to identify environmental road safety measures implemented in low- and middle-income countries (LMICs) to reduce pedestrian injuries from collisions with motor vehicles. METHODS: This review followed Arksey and O'Malley's approach and reported results using the PRISMA-SCR 2018 checklist. A literature review was conducted in Medline, Google Scholar, and the Transport Research International Documentation database using keyword-derived medical subject heading terms. A total of 14 articles met the pre-established inclusion criteria and were analyzed using a data extraction matrix. The findings were categorized methodically into three prominent themes: (1) methods for reducing pedestrian exposure, (2) traffic calming strategies, and (3) measures for enhancing pedestrian visibility. RESULTS: Traffic calming strategies, including vehicular speed reduction, roadway contraction, and vertical and horizontal diversionary tactics, emerged as the most effective interventions for reducing pedestrian injuries within LMICs. Conversely, interventions geared towards minimizing pedestrian exposure, such as zebra crossings, crosswalks controlled by traffic signals, underpasses, or overpasses, often produced minimal effects, and occasionally exacerbated the risk of pedestrian accidents. Lack of pedestrian visibility due to density of street vendors and parked vehicles was associated with a higher risk of injuries, while billboards impaired drivers' attention and increased the likelihood of collisions with pedestrians. DISCUSSION: In LMICs, the effectiveness of environmental measures in reducing vehicle-pedestrian crashes varies widely. In the face of resource constraints, implementing interventions for pedestrian safety in LMICs necessitates careful prioritization and consideration of the local context.

The prevalence and causes of visual impairment among the male homeless population of Montreal, Canada.

CLINICAL RELEVANCE: Homeless populations have lower health indicators, including in eye care. Few data exist on the levels and causes of visual impairment in Canadian homeless populations, and none in Montreal. BACKGROUND: This study aims to characterise the causes and levels of visual impairment, as well as eye care services utilisation among the Montreal homeless. METHODS: Using random sampling, five homeless shelters were selected. In each shelter, 20 participants were randomly selected. After obtaining informed consent, participants completed an ocular examination, which included: presenting visual acuity (pinhole as needed), intraocular pressure, confrontation visual field, dilated fundus examination, post-dilation autorefraction and questionnaire on social determinants of health. RESULTS: A total of 95 participants were examined, of which 97.9% were male. The median age was 49 years old (interquartile range 38-56.5). The age-adjusted prevalence of visual impairment (presenting visual acuity <6/12) was 23.6% (95% CI 15.1-32.9) compared to 6.0% in the Canadian population (Z = 77.9, p < 0.0001). With pinhole correction, the prevalence of visual impairment dropped to 5.8% (95% CI 1.7-11.8). Prevalence was 8.2% (95% CI 3.7-15.9) for cataracts, 11.4% (95% CI 5.9-19.7) for glaucoma or suspects and 4.7% (95% CI 1.7-11.9) for diabetic retinopathy. Lastly, 18.9% of participants had an ocular examination within the last year compared to 41.4% in Canada (Z = -4.5, p < 0.0001) and 13.7% had never had a comprehensive eye examination. CONCLUSIONS: This sample population shows a prevalence of visual impairment which is four times that of the general Canadian population, with highly prevalent uncorrected refractive error, while accessing primary eye care twice less often.

The sociodemographic characteristics and social determinants of visual impairment in a homeless population in the Montreal area.

OBJECTIVE: Homelessness is a serious social and public health concern in Canada. Individuals experiencing homelessness face numerous health problems and barriers in accessing health services. Visual impairment can exacerbate the lower quality of life experienced by people who are homeless, but its incidence among this population has been poorly documented in the literature. Our study aimed to describe health and sociodemographic characteristics and determine their association with visual impairment, ocular pathology and uncorrected refractive errors in a homeless population in Montreal, Canada. METHODS: This cross-sectional study was conducted between May 2019 and September 2020 in eight homeless shelters selected using a stratified random sampling approach on the island of Montreal. An eye examination was performed on all participants, who were also administered a survey on social determinants of health. Descriptive analysis was used to analyze survey data, and logistic regression was used for each of the three study outcomes. RESULTS: A total of 124 individuals experiencing homelessness (93 men, 31 women) were recruited. Participants were mostly Caucasian (> 70%) with an average age of 48 years (standard deviation = 13 years). Our sample reported a high level of education (68% had a high school diploma or higher), a high level of health insurance coverage (77%), social assistance benefits (71%), and social support (over 50%). There was a high prevalence of chronic conditions including diabetes (14%), hypertension (25%), and HIV/AIDS (3%). Results from eye examinations showed a high prevalence of visual impairment (22%), ocular pathology (23%), and uncorrected refractive error (75%). Age was statistically significantly associated with each outcome variable. CONCLUSION: Despite a high level of social and health support, individuals experiencing homelessness in Montreal, Canada, experience high levels of chronic conditions and visual impairment. Our study highlights the unmet need for eye healthcare among homeless populations, and that eye health can be a unique entry point for intervening with homeless populations.

RéSUMé: OBJECTIF: L'itinérance est un problème social et de santé publique important au Canada. Les personnes en situation d'itinérance font face à plusieurs problèmes de santé et d'accès aux soins de santé. La déficience visuelle est un problème de santé moins documenté chez cette population, mais qui peut grandement nuire à la qualité de vie. Notre étude visait à décrire les caractéristiques sanitaires et socio-démographiques et à déterminer leur association avec la déficience visuelle, les pathologies oculaires et les erreurs de réfraction non corrigée, dans une population d'itinérants à Montréal, au Canada. MéTHODOLOGIE: Une étude transversale a été réalisée entre mai 2019 et septembre 2020 auprès de 8 refuges pour itinérants à Montréal, sélectionnés par échantillonnage aléatoire stratifié. Les participants ont tous reçu un examen de la santé oculo-visuelle et il leur a été administré un questionnaire sur les déterminants sociaux de la santé. Une analyse descriptive a été utilisée pour analyser les données de l'enquête et une régression logistique a été utilisée pour chacun des trois variables dépendantes. RéSULTATS: Au total, 124 itinérants (93 hommes, 31 femmes) ont participé à l'étude. Les participants étaient caucasiens (>70 %) avec un âge moyen de 48 ans (±13 ans). Notre échantillon a déclaré un niveau d'éducation élevé (68 % avaient un diplôme d'études secondaires ou plus), un niveau élevé de couverture d'assurance maladie (77 %), d'aide sociale (71 %) et de soutien social (plus de 50 %). La prévalence des maladies chroniques était importante, notamment le diabète (14 %), l'hypertension (25 %) et le VIH/sida (3 %). Il y avait aussi une prévalence élevée de déficience visuelle (22 %), de pathologies oculaires (23 %) et d'erreurs réfractives non corrigées (75 %). L'âge était significativement associé à chacune des 3 variables dépendantes. CONCLUSION: Malgré un niveau élevé de soutien social et de santé, les itinérants de Montréal font face à un niveau élevé de maladies chroniques et de déficience visuelle. Notre étude met en évidence le niveau élevé des besoins non comblés en matière de soins de santé oculaire parmi les populations itinérantes, et le fait que la santé oculaire peut être un point d'entrée unique pour intervenir auprès de ces populations.