DECIDE: a cluster randomized controlled trial to reduce non-medically indicated caesareans in Burkina Faso.

BACKGROUND: Since 2006, Burkina Faso has subsidized the cost of caesarean sections to increase their accessibility. Caesareans are performed by obstetricians, general practitioners, and nurses trained in emergency surgery. While the national caesarean rate is still too low (only 2 % in 2010), 12 to 24 % of caesareans performed in hospital are, in fact, not medically indicated. The objective of this study is to evaluate the effectiveness and analyze the implementation of a multi-faceted intervention to lower the rate of non-medically indicated caesareans in Burkina Faso. METHODS: This study combines a multicentre cluster randomized controlled trial with an implementation analysis in a mixed-methods approach. The evidence-based intervention will consist of three strategies to improve the competencies of maternity teams: 1) clinical audits based on objective criteria; 2) training of personnel; and 3) decision-support reminders of indications for caesareans via text messages. The unit of randomization and of intervention is the public hospital equipped with a functional operating room. Using stratified randomization on hospital type and staff qualifications, 11 hospitals have been assigned to the intervention group and 11 to the control group. The intervention will cover 1 year. Every patient who delivered by caesarean during a 6-month period in the year preceding the intervention and the 6 months following its end will be included in the trial. The change in the rate of non-medically indicated caesareans is the main criterion by which the intervention's impact will be assessed. To analyze the intervention process, a longitudinal qualitative study consisting of deliberative workshops and individual in-depth interviews will be conducted. The target outcome is a 50 % reduction in the rate of non-medically indicated caesareans. DISCUSSION: This study will provide evidence regarding the effectiveness of a multi-faceted intervention for reducing non-medically indicated caesareans in a low-income country. By combining qualitative and quantitative methods, the study's findings will allow understanding the factors that could influence the intervention process and ultimately the intended outcomes. TRIAL REGISTRATION: The DECIDE trial is registered on the Current Controlled Trials website under the number ISRCTN48510263 on January 28, 2014.

The elimination of healthcare user fees for children under five substantially alleviates the burden on household expenses in Burkina Faso.

BACKGROUND: Since September 2008, an intervention has made it possible to provide free care to children under five in public health facilities in two districts of Burkina Faso. This study evaluated the intervention's impact on household expenses incurred for services (consultations and medications) to the children targeted. METHODS: The study is based on a survey of a representative panel of 1,260 households encountered in two waves, one month before and 12 months after the introduction of the intervention. The questions explored the illness episodes of all children under five in the 30 days before each wave. The analysis of health expenses incurred during an illness episode distinguished between total expenses and those incurred in public health facilities (charges for services and medications). Analyses based on multilevel simultaneous equation models were used to estimate the probability of spending and the amount spent, in a context where a large number of observations returned a count of zero. RESULTS: The burden on household expenses was greatly alleviated under the intervention. Average expenditure dropped from US$11 per episode of care to less than US$2 after the intervention was implemented. The risk of incurring an expense at a public health facility was reduced by two-thirds. The facility users' savings were primarily related to medication purchases. In rural areas, where barriers to access health services are more acute, both poor and non-poor families benefited from the intervention. The probability of spending on medications dropped dramatically for both the poor and the non-poor under the exemption (-75% vs.-77%), and the reduction in expenses for medications generated by the intervention was comparable for both groups in relative values (-86% vs.-89%). CONCLUSION: User fees abolition at the point of service substantially alleviated the burden on household expenses. The intervention benefited both poor and non-poor families and provided financial protection.

Determinants of non-medically indicated cesarean deliveries in Burkina Faso.

OBJECTIVE: To identify the factors associated with non-medically indicated cesarean deliveries (NMIC) in Burkina Faso in centers where user fees for cesarean delivery were partially removed. METHODS: We carried out a criteria-based audit in 22 referral hospitals, using data from a 6-month prospective observational study, to assess the proportion of NMIC. Multivariate logistic regression analyses were used to identify factors associated with NMIC. RESULTS: The decision of cesarean delivery was not medically indicated in 24% of cases. The factors independently associated with NMIC were urban residence (adjusted OR 1.55; 95% CI, 1.12-2.12; P=0.006), spouse's occupation other than breeder or farmer (aOR varying from 1.77 [95% CI, 1.19-2.62] to 2.15 [95% CI, 1.38-3.32] according to the profession), and cesarean decided by a general practitioner (aOR 1.61; 95% CI, 1.13-2.30; P=0.009). CONCLUSION: The high percentage of unnecessary cesarean deliveries is in contrast to the unmet needs of women who still deliver outside health facilities. NMIC is associated with both socioeconomic determinants and medical factors. Hence, interventions are needed to improve the skills of healthcare professionals and awareness of women concerning the risks associated with unnecessary cesarean delivery.

Endorsement of universal health coverage financial principles in Burkina Faso.

In West Africa, health system funding rarely involves cross-subsidization among population segments. In some countries, a few community-based or professional health insurance programs are present, but coverage is very low. The financial principles underlying universal health coverage (UHC) sustainability and solidarity are threefold: 1) anticipation of potential health risks; 2) risk sharing and; 3) socio-economic status solidarity. In Burkina Faso, where decision-makers are favorable to national health insurance, we measured endorsement of these principles and discerned which management configurations would achieve the greatest adherence. We used a sequential exploratory design. In a qualitative step (9 interviews, 12 focus groups), we adapted an instrument proposed by Goudge et al. (2012) to the local context and addressed desirability bias. Then, in a quantitative step (1255 respondents from the general population), we measured endorsement. Thematic analysis (qualitative) and logistic regressions (quantitative) were used. High levels of endorsement were found for each principle. Actual practices showed that anticipation and risk sharing were not only intentions. Preferences were given to solidarity between socio-economic status (SES) levels and progressivity. Although respondents seemed to prefer the national level for implementation, their current solidarity practices were mainly focused on close family. Thus, contribution levels should be set so that the entire family benefits from healthcare. Some critical conditions must be met to make UHC financial principles a reality through health insurance in Burkina Faso: trust, fair and mandatory contributions, and education.

Presence of three dengue serotypes in Ouagadougou (Burkina Faso): research and public health implications.

BACKGROUND: The significant malaria burden in Africa has often eclipsed other febrile illnesses. Burkina Faso's first dengue epidemic occurred in 1925 and the most recent in 2013. Yet there is still very little known about dengue prevalence, its vector proliferation, and its poverty and equity impacts. METHODS: An exploratory cross-sectional survey was performed from December 2013 to January 2014. Six primary healthcare centers in Ouagadougou were selected based on previously reported presence of Flavivirus. All patients consulting with fever or having had fever within the previous week and with a negative rapid diagnostic test (RDT) for malaria were invited to participate. Sociodemographic data, healthcare use and expenses, mobility, health-related status, and vector control practices were captured using a questionnaire. Blood samples of every eligible subject were obtained through finger pricks during the survey for dengue RDT using SD BIOLINE Dengue Duo (NS1Ag and IgG/IgM)® and to obtain blood spots for reverse transcription polymerase chain reaction (RT-PCR) analysis. In a sample of randomly selected yards and those of patients, potential Aedes breeding sites were found and described. Larvae were collected and brought to the laboratory to monitor the emergence of adults and identify the species. RESULTS: Of the 379 subjects, 8.7 % (33/379) had positive RDTs for dengue. Following the 2009 WHO classification, 38.3 % (145/379) had presumptive, probable, or confirmed dengue, based on either clinical symptoms or laboratory testing. Of 60 samples tested by RT-PCR (33 from the positive tests and 27 from the subsample of negatives), 15 were positive. The serotypes observed were DENV2, DENV3, and DENV4. Odds of dengue infection in 15-to-20-year-olds and persons over 50 years were 4.0 (CI 95 %: 1.0-15.6) and 7.7 (CI 95 %: 1.6-37.1) times higher, respectively, than in children under five. Average total spending for a dengue episode was 13 771 FCFA [1 300-67 300 FCFA] (1$US = 478 FCFA). On average, 2.6 breeding sites were found per yard. Potential Aedes breeding sites were found near 71.4 % (21/28) of patients, but no adult Aedes were found. The most frequently identified potential breeding sites were water storage containers (45.2 %). Most specimens collected in yards were Culex (97.9 %). CONCLUSIONS: The scientific community, public health authorities, and health workers should consider dengue as a possible cause of febrile illness in Burkina Faso.

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.