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Background Burkina Faso is among ten countries with the highest rates of malaria cases and deaths in the world. Delivery and coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) is insufficient in Burkina Faso; In a 2016 survey, only 22% of eligible women had received their third dose of IPTp. It is also an extremely rural country and one with an established cadre of community healthcare workers (CHWs). To better meet the needs of pregnant women, an enhanced programme was established to facilitate distribution of IPTp at the community level by CHWs. Methods In order to assess the perceptions of CHWs and facility healthcare workers (HCWs) involved in this programme rollout, semi-structured interviews were conducted at three high malaria burden health districts in Burkina Faso. Interviews were conducted at baseline with 104 CHWs and 35 HCWs prior to the introduction of community based IPTp (c-IPTp) to assess capacity and any areas of concern. At endline, interviews were conducted with 29 CHWs and 21 HCWs to identify key facilitators and suggestions for further implementation of the c-IPTp programme. Results CHWs reported feeling capable of supporting c-IPTp delivery and facilitating linkage to antenatal care (ANC). They noted that the opportunity for enhanced training and close and ongoing connections with facility HCWs and supportive supervision were imperative. Both CHWs and HCWs perceived this approach as acceptable to community members and noted the importance of close community engagement, monthly meetings between CHWs and facility HCWs, and maintaining regular supplies of sulfadoxine–pyrimethamine (SP). Those interviewed noted that it was beneficial to have the involvement of both female and male CHWs. Conclusions Community-based delivery of IPTp was feasible and acceptable to both facility HCWs and CHWs. This approach has the potential to strengthen delivery and uptake of IPTp and ANC both in Burkina Faso and across the region.

This study aimed to explore factors shaping the decision to undergo Human Immunodeficiency Virus (HIV) testing among men in rural Burkina Faso. 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. 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. 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.

Background Malaria in pregnancy is responsible for 8–14% of low birth weight and 20% of stillbirths in sub-Saharan Africa. To prevent these adverse consequences, the World Health Organization recommends intermittent preventive treatment of pregnant women (IPTp) with sulfadoxine–pyrimethamine be administered at each ANC visit starting as early as possible in the second trimester. Global IPTp coverage in targeted countries remains unacceptably low. Community delivery of IPTp was explored as a means to improve coverage. Methods A cluster randomized, controlled trial was conducted in 12 health facilities in a 1:1 ratio to either an intervention group (IPTp delivered by CHWs) or a control group (standard practice, with IPTp delivered at HFs) in three districts of Burkina Faso to assess the effect of IPTp administration by community health workers (CHWs) on the coverage of IPTp and antenatal care (ANC). The districts and facilities were purposively selected taking into account malaria epidemiology, IPTp coverage, and the presence of active CHWs. Pre- and post-intervention surveys were carried out in March 2017 and July–August 2018, respectively. A difference in differences (DiD) analysis was conducted to assess the change in coverage of IPTp and ANC over time, accounting for clustering at the health facility level. Results Altogether 374 and 360 women were included in the baseline and endline surveys, respectively. At baseline, women received a median of 2.1 doses; by endline, women received a median of 1.8 doses in the control group and 2.8 doses in the intervention group (p-value < 0.0001). There was a non-statistically significant increase in the proportion of women attending four ANC visits in the intervention compared to control group (DiD = 12.6%, p-value = 0.16). By the endline, administration of IPTp was higher in the intervention than control, with a DiD of 17.6% for IPTp3 (95% confidence interval (CI) − 16.3, 51.5; p-value 0.31) and 20.0% for IPTp4 (95% CI − 7.2, 47.3; p-value = 0.15). Conclusions Community delivery of IPTp could potentially lead to a greater number of IPTp doses delivered, with no apparent decrease in ANC coverage.

Background Successful efforts to encourage uptake of subdermal contraceptive implants, with a lifespan of three to five years, necessitate planning to ensure that quality removal services are available when desired. In Burkina Faso, implant use has tripled over the past 8 years and now comprises almost half of the contraceptive method mix. Population Monitoring for Action (PMA) surveys identified barriers to obtaining quality removal when desired, particularly when the implant is not palpable, or providers lack needed skills or supplies. The Expanding Family Planning Choices (EFPC) project supported ministries of health in four countries with evaluation and strengthening of implant removal services. Methods An implant removal landscape assessment was conducted at 24 health facilities in three regions of Burkina Faso with high implant use that included provider observations of implant removal, interviews with providers and health facility managers, and facility readiness surveys. The project used landscape data to mobilize stakeholders through a series of participatory workshops to develop a collaborative roadmap and commit to actions supporting quality implant removals. Results Landscape findings revealed key gaps in provision of quality removal services, including high levels of provider confidence for implant insertion and removal (82% and 71%, respectively), low competence performing simple and difficult removals (19.2% and 11.1%, respectively), inadequate supplies and equipment (no facilities had all necessary materials for removal), lack of difficult removal management systems, and a lack of standard data collection tools for removal. Exposure to the data convinced stakeholders to focus on removals rather than expanding insertion services. While not all roadmap commitments were achieved, the process led to critical investments in quality implant removals. Conclusion Landscape data revealed that facilities lack needed supplies and equipment, and providers lack skills needed to perform quality implant removals, limiting client reproductive choice. Disseminating this data enabled stakeholders to identify and commit to evidence-based priority actions. Stakeholders have since capitalized on program learnings and the roadmap, including following MOH guidance for implant removal supplies and health provider training. Our experience in Burkina Faso offers a replicable model of how data can direct collective action to improve quality of contraceptive implant removals.

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.

Background Although motivation of health workers in low- and middle-income countries (LMICs) has become a topic of increasing interest by policy makers and researchers in recent years, many aspects are not well understood to date. This is partly due to a lack of appropriate measurement instruments. This article presents evidence on the construct validity of a psychometric scale developed to measure motivation composition, i.e., the extent to which motivation of different origin within and outside of a person contributes to their overall work motivation. It is theoretically grounded in Self-Determination Theory (SDT). Methods We conducted a cross-sectional survey of 1142 nurses in 522 government health facilities in 24 districts of Burkina Faso. We assessed the scale’s validity in a confirmatory factor analysis framework, investigating whether the scale measures what it was intended to measure (content, structural, and convergent/discriminant validity) and whether it does so equally well across health worker subgroups (measurement invariance). Results Our results show that the scale measures a slightly modified version of the SDT continuum of motivation well. Measurements were overall comparable between subgroups, but results indicate that caution is warranted if a comparison of motivation scores between groups is the focus of analysis. Conclusions The scale is a valuable addition to the repository of measurement tools for health worker motivation in LMICs. We expect it to prove useful in the quest for a more comprehensive understanding of motivation as well as of the effects and potential side effects of interventions intended to enhance motivation.

We conducted the first population-based impact assessment of a financing policy introduced in Burkina Faso in 2007 on women's access to delivery services. The policy offers an 80 per cent subsidy for facility-based delivery. We collected information on delivery in five repeated cross-sectional surveys carried out from 2006 to 2010 on a representative sample of 1050 households in rural Nouna Health District. Over the 5 years, the proportion of facility-based deliveries increased from 49 to 84 per cent (P < 0.001). The utilization gap across socioeconomic quintiles, however, remained unchanged. The amount received for all services associated with births decreased by 67 per cent (P < 0.001), but women continued to pay on average 1423 CFA (€1 = 655 CFA), about 500 CFA more than the set tariff of 900 CFA. Our findings indicate the operational effectiveness of the policy in increasing the use of facility-based delivery services for women. The potential to reduce maternal mortality substantially has not yet been assessed by health outcome measures of neonatal and maternal mortality.

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. Les moustiquaires imprégnées (MI) sont un outil essentiel du programme mondial de lutte antipaludique. Un nombre croissant de pays africains ont entrepris des campagnes de distribution massive de moustiquaires imprégnées d’anti moustique faites pour durer (MID) avec pour but ultime la couverture universelle. En 2010, ce type de campagne a été mis place au Burkina Faso avec pour but que chaque ménage ait une moustiquaire pour deux. Notre objectif est d’évaluer l’effet de la couverture et de l’équité dans le processus de distribution universelle des MID au Burkina Faso et aussi d’identifier les facteurs déterminants qui font qu’un ménage est propriétaire d’une MI après la campagne. Nous avons évalué ces effets en comparant les données provenant de deux études distinctes sur les ménages menées début 2010 (avant la campagne) et début 2011 (après la campagne) dans un district rural représentatif du nordouest du Burkina Faso. Les données ont été recueillies selon les caractéristiques des ménages (y compris la situation socioéconomique) et suivant la détention d’une MI. Nous avons utilisé des courbes de concentration et des indices pour comparer les indicateurs de couverture avant et après la campagne. De même, nous avons utilisé une régression logistique multi-variable et multi-niveau afin d’estimer les facteurs associés à la réussite des objectifs de taux de couverture en 2011. L’enquête a été menée auprès de 1 106 ménages en 2010 et 1 094 en 2011. La proportion de ménages avec au moins une MI augmentait de 59% avant la campagne à 99% après, alors que l’indice de concentration tombait de 0,087 (SE: 0,014) à 0,002 (SE: 0,002). L’objectif d’une MI pour deux par ménage a atteint 52% des ménages avec un indice de concentration significatif de 0,031 (SE: 0,16). Environ 86% des ménages ont une MI pour trois. La taille de la famille et la distance jusqu’à un centre de santé sont les principales caractéristiques associées à l’objectif de couverture des ménages, en revanche le statut socioéconomique n’est pas associé. Pour conclure, même si les objectifs ne sont pas totalement atteints, la campagne nationale des MID est arrivée à un niveau élevé de couverture et a favorisé l’équité. 经杀虫剂处理的蚊帐对于中止疟疾的战略来说是十分重要的 工具。越来越多的非洲国家已经开始从事耐用的经杀虫剂处 理的蚊帐的大规模分配活动，从而达到全面覆盖的终极目 标。在 2010 年， 布基纳法索开展了一个以每两人获得一个 经杀虫剂处理的蚊帐为目标的全国范围活动。我们旨在评估 在布基纳法索的蚊帐全面分配活动的覆盖范围和公平性，并 且确定分配活动后跨家庭蚊帐所有权的决定因素。我们通过 对比 2010 年年初（分配活动开始前）和 2011 年年初（分配 活动开始后）在布基纳法索西北部典型的农村地区进行的两 个家庭调查的数据来评估全面分配活动的影响。我们基于家 庭特点（包括社会经济状况）和蚊帐所有权收集数据。我们 使用集中曲线和指数来对比活动前与活动后经杀虫剂处理蚊 帐的覆盖率指标，我们也使用多层面多变量的逻辑回归来估 计与达到 2011 年广泛覆盖范围目标相关的因素。该研究 2010 年涉及了1106 个家庭， 2011 年涉及了1094 个家 庭。我们发现至少拥有一个经杀虫剂处理蚊帐的家庭的比例 由分配活动前的 59% 上升为活动后的 99%，然而集中指数由 0.087(SE:0.014) 降低至 0.002(SE:0.002)。 52% 的家庭达到 了每个家庭每两人拥有一个经杀虫剂处理的蚊帐的目标，相 关集中指数为 0.031(SE:0.016) 。 86% 的家庭实现了每三个 人至少拥有一个经杀虫剂处理的蚊帐。家庭规模与距离健康 中心的距离，而非社会经济状况是与目标家庭覆盖范围显著 相关的主要特质。总之，尽管全国性的耐用经杀虫剂处理蚊 帐的发放活动没有完全其实现目标，但其实现了蚊帐高层次 的覆盖范围并且促进了公平性。 Los mosquiteros tratados con insecticida (MTI) son la herramienta fundamental de la estrategia Hacer Retroceder el Paludismo. Un número creciente de países africanos han emprendido campañas de distribución masiva de mosquiteros tratados con insecticidas de larga duración (MTILD) con el objetivo final de lograr cobertura universal. Este tipo de campaña nacional con el objetivo de un MTI por cada dos personas se ha llevado a cabo en Burkina Faso en 2010. Nuestro objetivo fue evaluar el efecto en la cobertura y la equidad de la campaña de distribución universal de MTILD en Burkina Faso e identificar los factores determinantes de la propiedad de MTI en los hogares después de la campaña. Se evaluaron sus efectos a través de la comparación de los datos de dos encuestas de hogares a principios de 2010 (antes de la campaña) y principios de 2011 (después de la campaña) en un distrito rural representativo en el noroeste de Burkina Faso. Se recopilaron datos sobre las características del hogar (incluyendo el estatus socioeconómico) y la propiedad de MTI. Se utilizaron curvas e índices de concentración para comparar los indicadores de cobertura de MTI antes y después de la campaña y regresión logística multivariante multinivel para estimar los factores asociados al logro de la meta de cobertura universal en 2011. La encuesta incluyó a 1.106 hogares en 2010 y 1.094 en 2011. Se encontró que la proporción de hogares con al menos un MTI aumentó de 59% antes de la campaña a 99% después, mientras que el índice de concentración se redujo de 0,087 (SE: 0,014) a 0,002 (SE: 0.002). Cincuenta y dos por ciento de hogares alcanzaron el objetivo de un MTI por cada dos personas por hogar, con el correspondiente índice de concentración de -0,031 (SE: 0,016). Ochenta y seis por ciento de hogares eran dueños de por lo menos un MTI por cada tres personas. Las principales características asociadas significativamente con la cobertura intra-hogar buscada eran el tamaño de la familia y la distancia al centro de salud, pero el estado no socioeconómico. En conclusión, a pesar de no haber cumplido plenamente su objetivo, la campaña nacional MTILD logró un alto nivel de cobertura y fomentó la equidad.

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. 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. 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. 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.