Addressing malnutrition among children in routine care: how is the Integrated Management of Childhood Illnesses strategy implemented at health centre level in Burundi?

BACKGROUND: The Integrated Management of Childhood Illness (IMCI) strategy was adopted in Burundi in 2003. Our aim was to evaluate to what extent the malnutrition component of the IMCI guidelines is implemented at health facilities level. METHODS: We carried out direct observations of curative outpatient consultations for children aged 6-59 months in 90 health centres selected randomly. We considered both the child and the health worker (HW) as units of analysis and used bivariate analysis to explore characteristics of HWs associated with tasks systematically or never performed. RESULTS: A total of 514 consultations carried out by 145 HWs were observed. Among the 250 children under two years, less than 30% were asked questions on breastfeeding. None of them had all seven nutrition-related questions asked to their caregivers and none of the 200 children over the age of two years had all five nutrition-related questions asked to their caregivers. Only 13 cases (3%) had all of the six examinations/tasks (weight, height/length, mid-upper arm circumference, oedema, filling in and discussing the growth curve and calculating the weight for height z-score) performed as part of their care. 393 cases (76%) reported that they had not being given any nutrition advice.With regards to HWs, among 99 of them who had received children under two, only 21 (21.2%)[14.2-30.5%) systematically asked the question regarding 'ongoing breastfeeding'.Only 56 (38.6%)[31-46.9%] weighed or discussed the weight taken prior the consultation for each child they reviewed, only 38 (26.2%)[19.6-34.1%] measured the height/length or discussed it for each child reviewed and 23 (15.9%)[10.7-22.8%] performed (systematically?) the WHZ-score.More than 50% never gave nutrition advices to any child reviewed.HWs who daily manage severe acute malnutrition were the most likely to systematically ask the question regarding 'ongoing breastfeeding' and to perform a 'weight examination'. Those who had not received supervision visit on the topic of malnutrition predominantly never performed a 'weight examination'. The 'height/length' examination' was predominantly performed by female HWs and those who have 'contract with the government. CONCLUSION: This study has found poor compliance by HWs to IMCI in Burundi. This indicates that a substantial proportion of children do not receive early and appropriate care, especially that pertaining to malnutrition. This alarming situation calls for strong action by actors committed to child health in the country. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).

"Ways and channels for voice regarding perceptions of maternal health care services within the communities of the Makamba and Kayanza provinces in the Republic of Burundi: an exploratory study".

BACKGROUND: Increased availability of maternal health services alone does not lead to better outcomes for maternal health.The services need to be utilized first.One way to increase service utilization is to plan responsive health care services by taking into account the community's views or expressed needs. Burundi has a high maternal mortality ratio, and despite improvements in health infrastructure, skilled staff and the abolition of user fees for pregnant women,utilization of maternal health services remains low. Possible reasons for this include a lack of responsive healthcare services. An exploratory study was conducted in 2013 in two provinces of Burundi (Makamba and Kayanza), with the aim to collect the experiences of women and men with the maternal health services,their views regarding those services, channels used to express these experiences, and the providers' reaction. METHODS: Semi-structured interviews were used to collect data from men and women and key informants, including community health workers, health committee members, health providers, local authorities, religious leaders and managers of non-governmental organizations. Data analysis was facilitated by MAXQDA 11 software. RESULTS: Negative experiences with maternal health services were reported and included poor staff behavior towards women and a lack of medicine. Health committees and suggestion boxes were introduced by the government to channel the community's views. However, they are not used by the community members, who prefer to use community health workers as intermediaries. Fear of expressing oneself linked to the post-war context of Burundi, social and gender norms, and religious norms limit the expression of community members' views, especially those of women. The limited appreciation of community health workers by the providers further hampers communication and acceptance of the community's views by health providers. CONCLUSION: In Burundi, the community voice to express views on maternal health services is encountering obstacles and needs to be strengthened,especially the women's voice. Community mobilization in the form of a mass immunization campaign day organized by women fora, and community empowerment using participatory approaches could contribute towards community voice strengthening.

Epilepsy and toxocariasis: a case-control study in Burundi.

PURPOSE: A case-control study to assess the relationship between epilepsy and toxocariasis was carried out in the Kiremba population, Burundi. METHODS: People with epilepsy (PWE) were diagnosed according to the definition proposed by the International League Against Epilepsy (ILAE). Seizures were classified according to the classification proposed by ILAE in 1981. One control per case was selected matched by age (+/-5 years). Control subjects also lived in Kiremba, had neither neurological disorders nor kinship with the PWE. Cases and controls were assessed serologically for antibodies against Toxocara canis by an immunoblotting assay. Odds ratios (ORs) and 95% CI were determined using conditional regression analysis for matched case-control study. RESULTS: One hundred ninety-one PWE (99 men and 92 women) and 191 age-matched controls (72 men and 112 women) were enrolled in the study. Of the 191 PWE, 113 presented partial seizures while 73 generalized seizures and five were unclassifiable. Antibodies anti T. canis were found in 114 PWE (59.7%) and in 97 controls (50.8%). Multivariate analysis (conditional logistic regression) showed a significant association between positivity for T canis and epilepsy with an adjusted OR of 2.13 (95% CI 1.18-3.83; p-value 0.01). CONCLUSIONS: We found a significant association between toxocariasis and epilepsy. In agreement with a previous study, our finding suggests that toxocariasis may increase the risk of developing epilepsy in endemic areas and could participate to the high burden of epilepsy in tropical areas.

Economic evaluation of epilepsy in Kiremba (Burundi): a case-control study.

PURPOSE: Epilepsy is a common disease whose prevalence across Africa is extremely variable (from 5 to 74 per thousand ). Its social and economic consequences in this continent are not well established. The objective of this study was to compare the cost of care of patients with epilepsy with that of controls in the commune of Kiremba in Burundi. METHODS: The survey was carried out in the commune of Kiremba from March 1, 2001, to April 30, 2001. A sample of cases (patients with epilepsy) and controls was taken from the general population. The economic analysis was conducted from the viewpoint of the patient. Data collected were direct medical costs (consultations, admissions to hospital, complementary examinations, treatments) and indirect costs (evaluated from the number of days of family life disrupted). RESULTS: In this study, 1,056 patients were included (352 patients with epilepsy and 704 controls). The total annual cost of patients with epilepsy was US dollars 11.0 against US dollars 7.3 for controls (p = 0.03). The indirect costs represented 75.8% of the total cost. For the people with epilepsy that took antiepileptic treatment (n = 18), the annual average total cost became US dollars 48.4. The number of disrupted days was 10.2 days (SD, 18.7 days) for the treated patients with epilepsy and 2.0 days (SD, 9.0 days) for the untreated ones (p < 0.001). CONCLUSIONS: Epilepsy was responsible for an extra cost: an increased direct cost along with more disruption of family life. This extra cost remained after adjustment for use of health care and antiepileptic treatments. Various measures could be envisioned to reduce the impact of indirect costs.

Cysticercosis as a major risk factor for epilepsy in Burundi, east Africa.

PURPOSE: Human cysticercosis is a direct consequence of infection by Taenia solium larvae (Cysticercus cellulosae). Results of studies on the impact of neurocysticercosis on epilepsy in Africa are inconsistent. The objective was to evaluate the role of cysticercosis in epilepsy in Burundi. METHODS: A prevalent matched case-control design was used in the Kiremba area, Burundi, between March and April 2001. One case with epilepsy was matched to two control subjects, according to their age. Cases were subjects who had shown at least two unprovoked epileptic seizures within a 24-h time range and who lived in the Kiremba area. The control subjects also lived in Kiremba and had neither neurologic illness nor kinship with the people with epilepsy. Seropositivity for cysticercosis was the exposure variable. Three hundred twenty-four prevalent cases, with onset of epilepsy between 1950 and 2000, and 648 age-matched controls were included. RESULTS: This study found a link between cysticercosis infestation and the occurrence of epilepsy (odds ratio, 3.8; 95% confidence interval, 2.5-5.1). CONCLUSIONS: The study highlighted the importance of cysticercosis in the area of Kiremba, as 31.5% of the control subjects screened positive for this parasite. The attributable risk for cysticercosis was 50% (95% confidence interval, 42-57) in this population.