Identifying Strengths and Gaps in Data Management and Reporting through Malaria Routine Data Quality Assessment: Results from Two Health Regions in Madagascar.

In 2021, the U.S. President's Malaria Initiative Measure Malaria project provided support to the National Malaria Program to conduct a data quality assessment. The main goal was to help health centers enhance the quality of their malaria data. The assessment involved reviewing data from outpatient registers, monthly reports, and DHIS2 data. Reporting timeliness, completeness, data element completeness, and availability of source documents were assessed. For timeliness, the assessment measured the proportion of reports that were submitted on time out of the expected total. The results showed that the reporting timeliness was inadequate in Atsinanana (85%) and adequate for Atsimo-Andrefana (95%). Data elements completeness, which refers to reports without missing data, was inadequate in Atsinanana (43%) and Atsimo-Andrefana (68%). The availability of source documents, such as records forms, was assessed and found to be 59% in Atsimo-Andrefana and 48% in Atsinanana. The use of standard reporting forms, which ensures consistency and accuracy in reporting, was reported to be 44% in Atsinanana and 54% in Atsimo-Andrefana. Data discrepancies were identified between outpatient registers, monthly reports, and DHIS2 data. A verification factor (VF) was used to compare the figures in these different sources. The VF was 1.2 in Atsinanana and 1.1 in Atsimo-Andrefana for both monthly reports and DHIS2 data, indicating an overreporting of fever cases tested in 6- to 13-year-olds. Overall, the assessment revealed gaps in data elements completeness, reporting accuracy, and availability of data recording guidelines. The findings suggest that regular data quality assessments should be implemented to guide decision making in Madagascar.

Lessons learned on teaching a global audience with massive open online courses (MOOCs) on health impacts of climate change: a commentary.

BACKGROUND: The adverse health impacts of climate change are increasing on a global level. However, knowledge about climate change and health is still unavailable to many global citizens, in particular on adaptation measures and co-benefits of health mitigation. Educational technologies, such as massive open online courses (MOOCs), may have a high potential for providing access to information about climate change links to health for a global audience. MAIN BODY: We developed three MOOCs addressing the link between climate change and health to take advantage of the methodology's broad reach and accelerate knowledge dissemination on the nexus of climate change and health. The primary objective was to translate an existing face-to-face short course that only reached a few participants on climate change and health into globally accessible learning opportunities. In the following, we share and comment on our lessons learned with the three MOOCs, with a focus on global teaching in the realm of climate change and health. CONCLUSIONS: Overall, the three MOOCs attracted a global audience with diverse educational backgrounds, and a large number of participants from low-income countries. Our experience highlights that MOOCs may play a part in global capacity building, potentially for other health-related topics as well, as we have found that our MOOCs have attracted participants within low-resource contexts. MOOCs may be an effective method for teaching and training global students on health topics, in this case on the complex links and dynamics between climate change and health and may further act as an enabler for equitable access to quality education.

A stakeholder workshop about modelled maps of key malaria indicator survey indicators in Madagascar.

The Demographic and Health Surveys (DHS) Program has supported three household Malaria Indicator Surveys (MIS) in Madagascar. The results of 13 key malaria indicators from these surveys have been mapped as continuous surfaces using model-based geostatistical methods. The opportunities and limitations of these mapped outputs were discussed during a workshop in Antananarivo, Madagascar in July 2018, attended by 15 representatives from various implementation, policy and research stakeholder institutions in Madagascar. Participants evaluated the findings from the maps, using these to develop figures and narratives to support their work in the control of malaria in Madagascar.

The use of video vignettes to measure health worker knowledge. Evidence from Burkina Faso.

The quality of care is a crucial determinant of good health outcomes, but is difficult to measure. Survey vignettes are a standard approach to measuring medical knowledge among health care providers. Given that written vignettes or knowledge tests may be too removed from clinical practice, particularly where "learning by doing" may be an important form of training, we developed a new type of provider vignette. It uses videos presenting a patient visiting the clinic with maternal/early childhood symptoms. We tested these video vignettes with current and future (students) health professionals in Burkina Faso. Participants indicated that the cases used were interesting, understandable and common. Their performance was consistent with expectations. Participants with greater training (medical doctors vs. nurses and midwives) and experience (health professionals vs. students) performed better. The video vignettes can easily be embedded in computers, tablets and smart phones; they are a convenient tool to measure provider knowledge; and they are cost-effective instruction and testing tools.

[Determinants of the choice of healthcare worker positions in rural areas in Burkina Faso.] / Déterminants du choix des postes en zone rurale par les professionnels de santé au Burkina Faso.

INTRODUCTION: In 2014, in Burkina Faso, more than 60% of healthcare workers were working in urban areas to the detriment of rural areas. The two largest cities concentrated the majority of healthcare workers, while these cities represent only 10% of the population. This study was designed to identify incentive strategies that could enable more equitable deployment of healthcare workers. METHODS: A cross-sectional survey was carried out in 2016 in six health regions in Burkina Faso. Key informant interviews were conducted to determine the factors influencing the choice of jobs. The results were used to construct job packages useful for the discrete choice experiment survey.Levels of preferences for 1,173 health workers for incentive packages linked to the job were explored by means of electronic questionnaire data collection.Sawtooth software was used to develop and randomize job pairing preferences proposed to healthcare workers. STATA14 software was used for mixed-logit analysis. RESULTS: The determinants to promote more equitable deployment and maintenance of health workers in their workplace include access to good accommodation, on-job training, responsibility, and improved salaries.In terms of acceptability of deployment, more than 75% (p-value < 0.001) of workers would agree to be redeployed in rural areas if the above conditions were met. CONCLUSION: Adequate and sustainable human resource development strategies should be set up by policymakers in order to improve the maintenance of healthcare workers in rural areas.

Climate Change and Health as Massive Open Online Courses.

To teach the basics of climate change and health - such as the nature of health impacts, best practices in adoption strategies and promotion in health co-benefits, mitigation and adaptation strategies - we have developed three massive open online courses (MOOCs). We analysed the three MOOCs with regards to different factors such as course content, student motivation, instructor behaviour, co-learner effects, design and implementation effects. We conducted online surveys for all three MOOCs based on the research model of Hone et al., extended with regards to student's motivation and course outcomes. In total, we evaluated 6898 students, of which 101 students took part in the online survey. We found differences in completion rates and country of origin for the three MOOCs. The francophone MOOC was found to have a high number of participants from lower-income- and low-and-middle-income countries. The majority of participants were aged between 22 and 40 years of age and had mainly a graduate educational background. The primary motivation to join the MOOC was the knowledge and skills gained as a result of taking the course. The three MOOCs on climate change and health had a reach of almost 7000 students worldwide, as compared to the scope of a face-to-face course on the same topic of 30 students, including students from resource-low environments that are already vulnerable to current changes in climate. The evaluation of the MOOCs outlined the current impact. However, further research has to be conducted to be able to get insights into the impact over time.

Vaccination coverage and factors associated with adherence to the vaccination schedule in young children of a rural area in Burkina Faso.

BACKGROUND: Vaccination is an important tool for reducing infectious disease morbidity and mortality. In the past, less than 80% of children 12-23 months of age were fully immunized in Burkina Faso. OBJECTIVES: To describe coverage and assess factors associated with adherence to the vaccination schedule in rural area Burkina Faso. METHODS: The study population was extracted from the Nouna Health and Demographic surveillance system cohort. Data from four rounds of interviews conducted between November 2012 and June 2014 were considered. This study included 4016 children aged 12-23 months. We assessed the effects of several background factors, including sex, factors reflecting access to health care (residence, place of birth), and maternal factors (age, education, marital status), on being fully immunized defined as having received Bacillus Calmette-Guérin (BCG), three doses of diphtheria-tetanus-pertussis and oral polio vaccine, and measles vaccine by 12 months of age. The associations were studied using binomial regression to derive prevalence ratios (PRs) in univariate and multivariate regression models. RESULTS: The full vaccination coverage increased significantly over time (72% in 2012, 79% in 2013, and 81% in 2014, p = 0.003), and the coverage was significantly lower in urban than in rural areas (PR 0.84; 0.80-0.89). Vaccination coverage was neither influenced by sex nor influenced by place of birth or by maternal factors. CONCLUSION: The study documented a further improvement in full vaccination coverage in Burkina Faso in recent years and better vaccination coverage in rural than in urban areas. The organization of healthcare systems with systematic outreach activities in the rural areas may explain the difference between rural and urban areas.

Situating mobile health: a qualitative study of mHealth expectations in the rural health district of Nouna, Burkina Faso.

BACKGROUND: The implementation of mobile health (mHealth) projects in low- and middle-income countries raises high and well-documented expectations among development agencies, policymakers and researchers. By contrast, the expectations of direct and indirect mHealth users are not often examined. In preparation for a proposed intervention in the Nouna Health District, in rural Burkina Faso, this study investigates the expected benefits, challenges and limitations associated with mHealth, approaching these expectations as a form of situated knowledge, inseparable from local conditions, practices and experiences. METHODS: The study was conducted within the Nouna Health District. We used a qualitative approach, and conducted individual semi-structured interviews and group interviews (n = 10). Participants included healthcare workers (n = 19), godmothers (n = 24), pregnant women (n = 19), women with children aged 12-24 months (n = 33), and women of childbearing age (n = 92). Thematic and content qualitative analyses were conducted. RESULTS: Participants expect mHealth to help retrieve patients lost to follow-up, improve maternal care monitoring, and build stronger relationships between pregnant women and primary health centres. Expected benefits are not reducible to a technological realisation (sending messages), but rather point towards a wider network of support. mHealth implementation is expected to present considerable challenges, including technological barriers, organisational challenges, gender issues, confidentiality concerns and unplanned aftereffects. mHealth is also expected to come with intrinsic limitations, to be found as obstacles to maternal care access with which pregnant women are confronted and on which mHealth is not expected to have any significant impact. CONCLUSIONS: mHealth expectations appear as situated knowledges, inseparable from local health-related experiences, practices and constraints. This problematises universalistic approaches to mHealth knowledge, while nevertheless hinting at concrete, expected benefits. Findings from this study will help guide the design and implementation of mHealth initiatives, thus optimising their chances for success.

An epidemiological study to assess Plasmodium falciparum parasite prevalence and malaria control measures in Burkina Faso and Senegal.

BACKGROUND: Malariometric information is needed to decide how to introduce malaria vaccines and evaluate their impact in sub-Saharan African countries. METHODS: This cross-sectional study (NCT01954264) was conducted between October and November, 2013, corresponding to the high malaria transmission season, in four sites with Health and Demographic Surveillance Systems (DSS) [two sites with moderate-to-high malaria endemicity in Burkina Faso (Nouna and Saponé) and two sites with low malaria endemicity in Senegal (Keur Socé and Niakhar)]. Children (N = 2421) were randomly selected from the DSS lists of the study sites and were stratified into two age groups (6 months-4 years and 5-9 years). A blood sample was collected from each child to evaluate parasite prevalence of Plasmodium falciparum and other Plasmodium species and gametocyte density by microscopy, and rapid diagnosis test in the event of fever within 24 h. Case report forms were used to evaluate malaria control measures and other factors. RESULTS: Plasmodium falciparum was identified in 707 (29.2%) children, with a higher prevalence in Burkina Faso than Senegal (57.5 vs 0.9% of children). In Burkina Faso, prevalence was 57.7% in Nouna and 41.9% in Saponé in the 6 months-4 years age group, and 75.4% in Nouna and 70.1% in Saponé in the 5-9 years age group. Infections with other Plasmodium species were rare and only detected in Burkina Faso. While mosquito nets were used by 88.6-97.0 and 64.7-80.2% of children in Burkina Faso and Senegal, other malaria control measures evaluated at individual level were uncommon. In Burkina Faso, exploratory analyses suggested that use of malaria treatment or any other medication within 14 days, and use of insecticide spray within 7 days decreased the prevalence of malaria infection; older age, rural residence, natural floor, grass/palm roof, and unavailability of electricity in the house were factors associated with increased malaria occurrence. CONCLUSIONS: Plasmodium falciparum infection prevalence in children younger than 10 years was 57.5% in Burkina Faso and 0.9% in Senegal, and variability was observed, among others, by age, study site and malaria control measures.

Strengthening individual capacity in monitoring and evaluation of malaria control programmes to streamline M&E systems and enhance information use in malaria endemic countries.

BACKGROUND: Malaria control interventions in most endemic countries have intensified in recent years and so there is a need for a robust monitoring and evaluation (M&E) system to measure progress and achievements. Providing programme and M&E officers with the appropriate skills is a way to strengthen malaria's M&E systems and enhance information use for programmes' implementation. This paper describes a recent effort in capacity strengthening for malaria M&E in sub-Saharan Africa (SSA). METHODS: From 2010 to 2014, capacity-strengthening efforts consisted of organizing regional in-person workshops for M&E of malaria programmes for Anglophone and Francophone countries in SSA in collaboration with partners from Ghana and Burkina Faso. Open-sourced online courses were also available in English. A post-workshop assessment was conducted after 5 years to assess the effects of these regional workshops and identify gaps in capacity. RESULTS: The regional workshops trained 181 participants from 28 countries from 2010 to 2014. Trained participants were from ministries of health, national malaria control and elimination programmes, non-governmental organizations, and development partners. The average score (%) for participants' knowledge tests increased from pretest to posttest for Anglophone workshops (2011: 59 vs. 76, 2012: 41 vs. 63, 2013: 51 vs. 73; 2014: 50 vs. 74). Similarly, Francophone workshop posttest scores increased, but were lower than Anglophone due to higher scores at pretest. (2011: 70 vs. 76, 2012: 74 vs. 79, 2013: 61 vs. 68; 2014: 64 vs. 75). Results of the post-workshop assessment revealed that participants retained practical M&E knowledge and skills for malaria programs, but there is a need for a module on malaria surveillance adapted to the pre-elimination context. CONCLUSION: The workshops were successful because of the curriculum content, facilitation quality, and the engagement of partner institutions with training expertise. Results from the post-workshop assessment will guide the curriculum's development and restructuring for the next phase of workshops. Country-specific malaria M&E capacity needs assessments may also inform this process as countries reduce malaria burden.

Health worker preferences for performance-based payment schemes in a rural health district in Burkina Faso.

BACKGROUND: One promising way to improve the motivation of healthcare providers and the quality of healthcare services is performance-based incentives (PBIs) also referred as performance-based financing. Our study aims to explore healthcare providers' preferences for an incentive scheme based on local resources, which aimed at improving the quality of maternal and child health care in the Nouna Health District. DESIGN: A qualitative and quantitative survey was carried out in 2010 involving 94 healthcare providers within 34 health facilities. In addition, in-depth interviews involving a total of 33 key informants were conducted at health facility levels. RESULTS: Overall, 85% of health workers were in favour of an incentive scheme based on the health district's own financial resources (95% CI: [71.91; 88.08]). Most health workers (95 and 96%) expressed a preference for financial incentives (95% CI: [66.64; 85.36]) and team-based incentives (95% CI: [67.78; 86.22]), respectively. The suggested performance indicators were those linked to antenatal care services, prevention of mother-to-child human immunodeficiency virus transmission, neonatal care, and immunization. CONCLUSIONS: The early involvement of health workers and other stakeholders in designing an incentive scheme proved to be valuable. It ensured their effective participation in the process and overall acceptance of the scheme at the end. This study is an important contribution towards the designing of effective PBI schemes.

Quality of antenatal and childbirth care in rural health facilities in Burkina Faso, Ghana and Tanzania: an intervention study.

OBJECTIVE: To assess the impact of an intervention consisting of a computer-assisted clinical decision support system and performance-based incentives, aiming at improving quality of antenatal and childbirth care. METHODS: Intervention study in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania. In each country, six intervention and six non-intervention PHC facilities, located in one intervention and one non-intervention rural districts, were selected. Quality was assessed in each facility by health facility surveys, direct observation of antenatal and childbirth care, exit interviews, and reviews of patient records and maternal and child health registers. Findings of pre- and post-intervention and of intervention and non-intervention health facility quality assessments were analysed and assessed for significant (P < 0.05) quality of care differences. RESULTS: Post-intervention quality scores do not show a clear difference to pre-intervention scores and scores at non-intervention facilities. Only a few variables had a statistically significant better post-intervention quality score and when this is the case this is mostly observed in only one study-arm, being pre-/post-intervention or intervention/non-intervention. Post-intervention care shows similar deficiencies in quality of antenatal and childbirth care and in detection, prevention, and management of obstetric complications as at baseline and non-intervention study facilities. CONCLUSION: Our intervention study did not show a significant improvement in quality of care during the study period. However, the use of new technology seems acceptable and feasible in rural PHC facilities in resource-constrained settings, creating the opportunity to use this technology to improve quality of care.

Understanding home delivery in a context of user fee reduction: a cross-sectional mixed methods study in rural Burkina Faso.

BACKGROUND: Several African countries have recently reduced/removed user fees for maternal care, producing considerable increases in the utilization of delivery services. Still, across settings, a conspicuous number of women continue to deliver at home. This study explores reasons for home delivery in rural Burkina Faso, where a successful user fee reduction policy is in place since 2007. METHODS: The study took place in the Nouna Health District and adopted a triangulation mixed methods design, combining quantitative and qualitative data collection and analysis methods. The quantitative component relied on use of data from the 2011 round of a panel household survey conducted on 1130 households. We collected data on utilization of delivery services from all women who had experienced a delivery in the previous twelve months and investigated factors associated with home delivery using multivariate logistic regression. The qualitative component relied on a series of open-ended interviews with 55 purposely selected households and 13 village leaders. We analyzed data using a mixture of inductive and deductive coding. RESULTS: Of the 420 women who reported a delivery, 47 (11 %) had delivered at home. Random effect multivariate logistic regression revealed a clear, albeit not significant trend for women from a lower socio-economic status and living outside an area to deliver at home. Distance to the health facility was found to be positively significantly associated with home delivery. Qualitative findings indicated that women and their households valued facility-based delivery above home delivery, suggesting that cultural factors do not shape the decision where to deliver. Qualitative findings confirmed that geographical access, defined in relation to the condition of the roads and the high transaction costs associated with travel, and the cost-sharing fees still applied at point of use represent two major barriers to access facility-based delivery. CONCLUSIONS: Findings suggest that the current policy in Burkina Faso, as similar policies in the region, should be expanded to remove fees at point of use completely and to incorporate benefits/solutions to support the transport of women in labor to the health facility in due time.

An insecticide-treated bed-net campaign and childhood malaria in Burkina Faso.

OBJECTIVE: To investigate if the first national insecticide-treated bed-net campaign in Burkina Faso, done in 2010, was followed by a decrease in childhood malaria in a district with high baseline transmission of the disease. METHODS: We obtained data on the prevalence of Plasmodium falciparum parasitaemia in children aged 2 weeks to 36 months from malaria surveys in 2009 and 2011. We assessed morbidity in children younger than 5 years by comparing data from the Nouna health district's health management information system before and after the campaign in 2010. We analysed mortality data from 2008 to 2012 from Nouna's health and demographic surveillance system. FINDINGS: The bed-net campaign was associated with an increase in the reported use of insecticide-treated nets. In 2009, 73% (630/869) of children reportedly slept under nets. In 2011, 92% (449/487) did. The campaign had no effect on the proportion of young children with P. falciparum parasitaemia after the rainy season; 52% (442/858) in 2009 and 53% (263/499) in 2011. Cases of malaria increased markedly after the campaign, as did the number of children presenting with other diseases. The campaign was not associated with any changes in child mortality. CONCLUSION: The 2010 insecticide-treated net campaign in Burkina Faso was not associated with a decrease in care-seeking for malaria or all-cause mortality in children younger than 5 years. The most likely explanation is the high coverage of nets in the study area before the campaign which could have had an effect on mosquito vectors, limiting the campaign's impact.

Factors Affecting the Uptake of HIV Testing among Men: A Mixed-Methods Study in Rural Burkina Faso.

BACKGROUND: This study aimed to explore factors shaping the decision to undergo Human Immunodeficiency Virus (HIV) testing among men in rural Burkina Faso. METHODS: The study took place in 2009 in the Nouna Health District and adopted a triangulation mixed methods design. The quantitative component relied on data collected through a structured survey on a representative sample of 1130 households. The qualitative component relied on 38 in-depth interviews, with men purposely selected to represent variation in testing decision, age, and place of residence. A two-part model was conducted, with two distinct outcome variables, i.e. "being offered an HIV test" and "having done an HIV test". The qualitative data analysis relied on inductive coding conducted by three independent analysts. RESULT: Of the 937 men, 357 had been offered an HIV test and 97 had taken the test. Younger age, household wealth, living in a village under demographic surveillance, and knowing that HIV testing is available at primary health facilities were all positively associated with the probability of being offered an HIV test. Household wealth and literacy were found to be positively associated, and distance was found to be negatively associated with the probability of having taken an HIV test. Qualitative findings indicated that the limited uptake of HIV testing was linked to poor knowledge on service availability and to low risk perceptions. CONCLUSION: With only 10% of the total sample ever having tested for HIV, our study confirmed that male HIV testing remains unacceptably low in Sub-Saharan Africa. This results from a combination of health system factors, indicating general barriers to access, and motivational factors, such as one's own knowledge of service availability and risk perceptions. Our findings suggested that using antenatal care and curative services as the exclusive entry points into HIV testing may not be sufficient to reach large portions of the male population. Thus, additional strategies are urgently needed to increase service uptake.

Insecticide-treated mosquito nets in rural Burkina Faso: assessment of coverage and equity in the wake of a universal distribution campaign.

Insecticide-treated mosquito nets (ITNs) are an essential tool of the Roll Back Malaria strategy. An increasing number of African countries have embarked on mass distribution campaigns of long-lasting insecticide-treated nets (LLINs) with the ultimate goal of universal coverage. Such a national campaign with the goal of one ITN for every two people has been conducted in Burkina Faso in 2010. Our aim was to assess the coverage and equity effect of the universal distribution campaign of LLINs in Burkina Faso and to identify determinants of ITN ownership across households after the campaign. We evaluated its effects through comparison of data from two household surveys conducted in early 2010 (before the campaign) and early 2011 (after the campaign) on a representative rural district in north-western Burkina Faso. Data were collected on household characteristics (including socio-economic status) and ITN ownership. We used concentration curves and indices to compare ITN coverage indicators before and after the campaign and multilevel multivariate logistic regression to estimate factors associated with achievement of the universal coverage target in 2011. The survey included 1106 households in 2010 and 1094 in 2011. We found that the proportion of households with at least one ITN increased from 59% before the campaign to 99% afterwards, whereas the concentration index dropped from 0.087 (standard error (SE): 0.014) to 0.002 (SE: 0.002). Fifty-two per cent of households reached the target of one ITN for every two people per household, with the relevant concentration index at -0.031 (SE: 0.016). Eighty-six per cent of households owned at least one ITN for every three people. The main characteristics significantly associated with the targeted intra-household coverage were family size and distance to the health centre but not socio-economic status. In conclusion, despite not having fully met its target, the national LLIN campaign achieved a high level of coverage and fostered equity.

Malaria mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites.

BACKGROUND: Malaria continues to be a major cause of infectious disease mortality in tropical regions. However, deaths from malaria are most often not individually documented, and as a result overall understanding of malaria epidemiology is inadequate. INDEPTH Network members maintain population surveillance in Health and Demographic Surveillance System sites across Africa and Asia, in which individual deaths are followed up with verbal autopsies. OBJECTIVE: To present patterns of malaria mortality determined by verbal autopsy from INDEPTH sites across Africa and Asia, comparing these findings with other relevant information on malaria in the same regions. DESIGN: From a database covering 111,910 deaths over 12,204,043 person-years in 22 sites, in which verbal autopsy data were handled according to the WHO 2012 standard and processed using the InterVA-4 model, over 6,000 deaths were attributed to malaria. The overall period covered was 1992-2012, but two-thirds of the observations related to 2006-2012. These deaths were analysed by site, time period, age group and sex to investigate epidemiological differences in malaria mortality. RESULTS: Rates of malaria mortality varied by 1:10,000 across the sites, with generally low rates in Asia (one site recording no malaria deaths over 0.5 million person-years) and some of the highest rates in West Africa (Nouna, Burkina Faso: 2.47 per 1,000 person-years). Childhood malaria mortality rates were strongly correlated with Malaria Atlas Project estimates of Plasmodium falciparum parasite rates for the same locations. Adult malaria mortality rates, while lower than corresponding childhood rates, were strongly correlated with childhood rates at the site level. CONCLUSIONS: The wide variations observed in malaria mortality, which were nevertheless consistent with various other estimates, suggest that population-based registration of deaths using verbal autopsy is a useful approach to understanding the details of malaria epidemiology.

Counselling on and women's awareness of pregnancy danger signs in selected rural health facilities in Burkina Faso, Ghana and Tanzania.

OBJECTIVE: The aims of this study were to (i) assess healthcare workers' counselling practices concerning danger signs during antenatal consultations in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania; to (ii) assess pregnant women's awareness of these danger signs; and (iii) to identify factors affecting counselling practices and women's awareness. METHODS: Cross-sectional study in rural PHC facilities in Burkina Faso, Ghana and Tanzania. In each country, 12 facilities were randomly selected. WHO guidelines were used as standard for good counselling. We assessed providers' counselling practice on seven danger signs through direct observation study (35 observations/facility). Exit interviews (63 interviews/facility) were used to assess women's awareness of the same seven danger signs. We used negative binomial regression to assess associations with health services' and socio-demographic characteristics and to estimate per study site the average number of danger signs on which counselling was provided and the average number of danger signs mentioned by women. RESULTS: About one in three women was not informed of any danger sign. For most danger signs, fewer than half of the women were counselled. Vaginal bleeding and severe abdominal pain were the signs most counselled on (between 52% and 66%). At study facilities in Burkina Faso, 58% of the pregnant women were not able to mention a danger sign, in Ghana this was 22% and in Tanzania 30%. Fever, vaginal bleeding and severe abdominal pain were the danger signs most frequently mentioned. The type of health worker (depending on the training they received) was significantly associated with counselling practices. Depending on the study site, characteristics significantly associated with awareness of signs were women's age, gestational age, gravidity and educational level. CONCLUSION: Counselling practice is poor and not very efficient. A new approach of informing pregnant women on danger signs is needed. However, as effects of antenatal care education remain largely unknown, it is very well possible that improved counselling will not affect maternal and newborn mortality and morbidity.