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.

Towards a deeper understanding of male involvement in the prevention of mother to child transmission of HIV in the Bogodogo District of the Central Region of Burkina Faso.

INTRODUCTION: Men can play crucial roles at each stage of HIV mother-to-child-transmission (MTCT) prevention. Low male involvement in preventative MTCT (PMTCT) in Burkina Faso is partially associated with increased MTCT rates in the country. Male involvement is at the intersection of individual experiences, social locations, organizational and systemic forces. It is crucial that PMTCT interventions are co-designed with all stakeholders, using approaches which account for such interconnected elements. This study, aims to provide a deeper understanding of male involvement using an intersectionality framework. METHODS: We used an intersectional theoretical approach as it positions male involvement at the intersection of social location, systemic forces, individual experiences, and dynamics within couples. We applied an interpretative qualitative description design. The study was performed at St-Camille's hospital in Ouagadougou, Burkina Faso. Our sample was theoretical to contrast for individual experiences and socioeconomic characteristics. Eligible women were identified via chart review and invited to participate with their male partners. We conducted individual semi-structured interviews with 12 couples. We performed a semantic thematic analysis using QDA Miner to identify themes and patterns among subjective perspectives, while accounting for variations between individuals. RESULTS: We interviewed 12 couples; 6 were serodiscordant. All women were HIV-positive. Participant ages ranged from 23 to 48 years. We found male involvement to be multidimensional and multifaceted, covering a large spectrum (from rejection to true partnership) and diverse involvement. Male involvement was limited by competing priorities, contradictory expectations, organizational opportunities and societal beliefs. We found interactions with caregivers impacted male involvement. CONCLUSION: This study contributed to enhancing our understanding of male involvement in PMTCT of HIV as a dynamic result of the interconnected individual, organizational and systemic experiences. Increasing male involvement will require implementation of coordinated interventions. Such interventions must strive to simultaneously integrate individual, organizational and systemic actions together.

Does abolishing user fees for family planning increase contraception use? An impact evaluation of the national policy in Burkina Faso.

Background: Unmet needs for contraception constitute a major public health problem in sub-Saharan Africa. Several mechanisms have been tested to reduce the financial barrier and facilitate access to family planning services, with inconclusive results. Based on the positive impacts following the introduction of free health care for pregnant women, Burkina Faso decided to extend its national policy and abolished direct payment for family planning services. This study aims to evaluate the impact of this policy on contraceptive use and unmet needs for contraception among women of reproductive age (WRA) in Burkina Faso. Methods: This study uses two different study designs to examine the impact of a user fee removal policy on contraceptive use across a panel of 1400 households randomly selected across eight health districts. Data were collected using a standardized socio-demographic questionnaire at three different time points during the pilot and scale-up phases of the fee abolition program. The questionnaire was administered six months after the launch of the pilot fee abolition program in four health districts. For the remaining four health districts, the survey was conducted one year prior to and six months after the implementation of the program in those areas. All WRA in the households were eligible to participate. A cross-sectional study design was used to determine the association between knowledge of the fee abolition policy among WRA and actual use of contraceptives by WRA six months after the policy's implementation and across all eight districts. Additionally, a pre-post study with a non-randomized, reflexive control group was designed using repeated surveys in four health districts. Hierarchical logistic mixed effects models were adjusted for a set of time-variant individual variables; the impact was assessed by a difference-in-differences approach that compared pre-post changes in contraception use in women who knew about the new policy and those who did not. Results: Of the 1471 WRA surveyed six months after the removal of user fees for family planning services, 56% were aware of the policy's existence. Knowledge of the fee abolition policy was associated with a 46% increase probability of contraceptive use among WRA six months after the policy's implementation. Among the subset of the participants who were surveyed twice (n = 507), 65% knew about the fee removal policy six months after its introduction and constitute the intervention group. Pre-post changes in contraceptive use differed significantly between the intervention (n = 327) and control groups (n = 180). Removing user fees for family planning led to an 86% (95% confidence interval (CI) = 0.49, 1.31) increase in the likelihood of using contraception. In the study area, the policy reduced the prevalence of unmet needs for contraception by 13 percentage points. Conclusions: Removing user fees for family planning services is a promising strategy to increase access to, and reduce unmet needs for, contraception. A broader dissemination of the policy's existence will likely increase its impact on the overall population.

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.

Change in childbearing intention, use of contraception, unwanted pregnancies, and related adverse events during the COVID-19 pandemic: Results from a panel study in rural Burkina Faso.

Evidence on how the COVID-19 pandemic has affected women's reproductive health remains scarce, particularly for low- and middle-income countries. Deleterious indirect effects seem likely, particularly on access to contraception and risk of unwanted pregnancies, but rigorous evaluations using quasi-experimental designs are lacking. Taking a diachronic perspective, we aimed to investigate the effects of the pandemic on four indicators of women's reproductive health: history of recent adverse events during pregnancy (past), use of contraception and unwanted pregnancies (present), and childbearing intentions (future). This study was conducted in four rural health districts of Burkina Faso: Banfora, Leo, Sindou and Tenado. Two rounds of household surveys (before and during the pandemic) were conducted in a panel of 696 households using standardized questionnaires. The households were selected using a stratified two-stage random sampling method. All women aged 15-49 years living in the household were eligible for the study. The same households were visited twice, in February 2020 and February 2021. The effects were estimated by fitting hierarchical regression models with fixed effects or random intercepts at the individual level. A total of 814 and 597 women reported being sexually active before and during the COVID-19 pandemic, respectively. The odds of not wanting (any more) children were two times higher during the pandemic than before (2.0, 95% CI [1.32-3.04]). Among those with childbearing intention, the average desired delay until the next pregnancy increased from 28.7 to 32.8 months. When comparing 2021 versus 2020, there was an increase in the adjusted odds ratio of contraception use (1.23, 95% CI [1.08-1.40]), unwanted pregnancies (2.07, 95% CI [1.01-4.25]), and self-reported history of miscarriages, abortions, or stillbirths in the previous 12 months (2.4, 95% CI [1.04-5.43]). Our findings in rural Burkina Faso do not support the predicted detrimental effects of COVID-19 on the use of family planning services in LMICs, but confirm that it negatively affects pregnancy intentions. Use of contraception increased significantly among women in the panel, but arguably not enough to avoid an increase in unwanted pregnancies.

Free healthcare for some, fee-paying for the rest: adaptive practices and ethical issues in rural communities in the district of Boulsa, Burkina Faso.

In Burkina Faso, in July 2016, user fees were removed at all public healthcare facilities, but only for children under 60 months of age and for "mothers", i.e. for reproductive care. This study was conducted in five rural communities in Boulsa District (Burkina Faso) (1) to understand the perceptions and practices of stakeholders regarding compliance with eligibility criteria for free care and (2) to explore the ethical tensions that may have resulted from this policy. Semi-directed individual interviews (n = 20) were conducted with healthcare personnel and mothers of young children. Interviews were recorded and transcribed, and a thematic content analysis was conducted. The study reveals the presence of practices to circumvent strict compliance with the eligibility criteria for free access. These include hiding the exact age of children over 60 months and using eligible persons for the benefit of others. These practices result from ethical and economic tensions experienced by the beneficiaries. They also raise dilemmas among healthcare providers, who have to enforce compliance with the eligibility criteria while realizing the households' deprivation. Informal adjustments are introduced at the community level to reconcile the healthcare providers' dissonance. Local reinvention mechanisms help in overcoming ethical tensions and in implementing the policy.

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.

Longitudinal analysis of the capacities of community health workers mobilized for seasonal malaria chemoprevention in Burkina Faso.

BACKGROUND: Seasonal malaria chemoprevention (SMC) relies on community health workers to distribute drugs. This study assessed: (1) the capacity of community-based distributors (CBDs) at the start and end of a campaign and from one campaign to another after training or refresher courses before each round; (2) to what extent CBDs' experience over several campaigns contributed to measurable increase in their capacities; and (3) to what extent the training and experience of committed CBDs helped the less productive to catch up. METHODS: A longitudinal analysis was conducted in one Burkina Faso health district during the 2017 and 2018 campaigns. A panel including all CBDs was created. Their capacities were observed after: (1) initial training for the 2017 season; (2) refresher training for that year's fourth round; and (3) initial training for the 2018 season. All were invited to complete a questionnaire at the end of training with 27 multiple-choice questions on their main tasks. Observers noted content coverage and conditions under which training sessions were conducted. RESULTS: The 612 CBDs showed, on average, high understanding of their tasks from the start of the annual campaigns. Tasks related to communicating with parents and reporting were best mastered. Their capacities grew from round to round and campaign to campaign, after most had undergone training and been supervised by head nurses. The greatest progress was in the technical components, considered more complex, which involved selecting eligible children, choosing the correct drug packet, and referring children to health professionals. Retaining CBDs from one round to the next benefited everyone, whatever their starting level. Groups that initially obtained the lowest scores (women, illiterates, youngest/oldest) progressed the most. CONCLUSION: These results confirm the potential of using CBDs under routine programme implementation. Mandating CBDs with targeted tasks is a functional model, as they achieve mastery in this context where investments are made in training and supervision. Losing this specificity by extending CBDs' mandates beyond SMC could have undesirable consequences. The added value of retaining committed CBDs is high. It is suggested that motivation and commitment be considered in recruitment, and that a supportive climate be created to foster retention.

Analysis of the quality of seasonal malaria chemoprevention provided by community health Workers in Boulsa health district, Burkina Faso.

BACKGROUND: Since 2014, the Burkina Faso government has made Seasonal Malaria Chemoprevention (SMC) a priority in its strategic plan to fight against malaria among children aged from 3 to 59 months. Very few studies have examined the care provided by community health workers in the framework of this strategy. The purpose of this study was to evaluate the level of quality of care provided by the latter. METHODS: This was a mixed study. The quantitative component consisted of a non-participant observation of community health workers during the administration of care. The qualitative component consisted of one-on-one interviews with community health workers, child caregivers and head nurses. Five dimensions (organizational accessibility, interpersonal relationship, technical competence, safety of care and satisfaction of child caregivers) adapted from the Donabedian quality of care model were used to assess the quality level of care. The Corlien et al. Health Systems Research Program Implementation Scale was used to establish quality scores for each of the five dimensions. The study sites were the health centers located in the administrative centers of the 4 communes of the health district of Boulsa. The data were collected during the first cycle of the 2017 SMC campaign. RESULTS: A total of 14 active pairs (28 CHWs) were observed and 40 in-depth interviews with community health workers, Head nurses in duty and community leaders were conducted. The results show that community health workers worked in pairs. They had all received SMC training and possessed equipment to do their job. The dimensions of organizational accessibility and satisfaction of the caregivers were rated as good. The dimensions of interpersonal relationship and technical competence were judged to be of an acceptable score. Safety of care was judged to be of a low-level score. The overall quality of care was considered acceptable. CONCLUSION: The results of this study have shown that despite the difficulties faced by community health workers, they manage to deliver acceptable quality of care. Their use would be an asset for SMC in particular and for the health system in general.