Assessing the effect of seasonal malaria chemoprevention on malaria burden among children under 5 years in Burkina Faso.

BACKGROUND: In 2014, the Burkina Faso government launched the Seasonal Malaria Chemoprevention (SMC) programme. Expected benefit was a 75% reduction of all malaria episodes and a 75% drop of severe malaria episodes. This study assessed SMC efficiency on malaria morbidity in the country after 2 years of implementation. METHODS: Quasi-experimental design comparing changes in outcomes during the high transmission period (August-November) between SMC and non-SMC health districts before (2013-2014) and after intervention (two rounds in 2015 and 2016). Health indicators (number of uncomplicated malaria cases (UM) and severe malaria cases (SM)) from 19 health districts (8 in intervention and 11 in comparison group) were extracted from the District Health Information System (DHIS2)-based platform including health facilities data. Effect on incidence was assessed by fitting difference-in difference mixed-effects negative binomial regression model at a log scale. RESULTS: The two rounds of SMC were associated with a reduction of UM incidence (ratio of incidence rate ratio (IRR) 69% (95% CI 55-86%); p = 0.001) and SM incidence (ratio of IRR = 73% (55-95%), p = 0.018) among under five children. CONCLUSION: The two rounds of SMC had a significant effect on the reduction of malaria cases in under five children. This additional evidence on the effectiveness of SMC, using routine data, support the need to sustain its implementation and consider expansion to eligible areas not yet covered.

What are the trends in seeking health care for fever in children under-five in Sierra Leone? evidence from four population-based studies before and after the free health care initiative.

BACKGROUND: In 2010, the government of Sierra Leone implemented the Free Health Care Initiative (FHCI) in the country with the objective of reducing the high maternal, infant, and child mortality rates and improving general health indicators. The objective of this study was to assess the trends in the prevalence of health care-seeking and to identify the determinants of healthcare service utilization by caregivers of children younger than five years. METHODS: The analysis of health-care-seeking behavior was done using data from four population-based surveys in Sierra Leone before (2008) and after (2013, 2016, 2019) the FHCI was implemented. Care-seeking behavior was assessed with regard to caregivers seeking care for children under-five in the two weeks prior to each survey. We compared the percentages of healthcare-seeking behavior change and identify factors associated with healthcare-seeking using a modified Poisson regression model with generalized estimating equations. RESULTS: In 2008, a total of 1208 children with fever were recorded, compared with 2823 children in 2013, 1633 in 2016, and 1464 in 2019. Care-seeking for children with fever was lowest in 2008 (51%; 95% CI (46.4-55.5)) than in 2013 (71.5%; 95% CI (68.4-74.5)), 2016 (70.3%; 95% CI (66.6-73.8)), and 2019 (74.6%; 95% CI (71.6-77.3)) (p < 0.001). Care-seeking in 2013, 2016 and 2019 was at least 1.4 time higher than in 2008 (p < 0.001) after adjusting for mother's age, wealth, religion, education level, household head and the child's age. Care-seeking was lowest for children older than 12 months, mothers older than 35 years, children living in the poorest households, and in the northern region. A trend was observed for the sex of the household head. The level of care-seeking was lowest when the household head was a man. CONCLUSIONS: The increase in healthcare-seeking for children under-five with fever followed the introduction of the FHCI in Sierra Leone. Care-seeking for fever varied by the child's age, caregiver's age, household wealth, the sex of the household head and region. Maintaining the FHCI with adequate strategies to address other barriers beyond financial ones is essential to reduce disparities between age groups, regions and, households.

Using geographically weighted Poisson regression to examine the association between socioeconomic factors and hysterectomy incidence in Wallonia, Belgium.

BACKGROUND: Various studies have investigated geographical variations in the incidence of hysterectomy in Western countries and analyzed socioeconomic factors to explain those variations. However, few studies have used spatial analysis to characterize them. Geographically weighted Poisson regression (GWPR) explores the spatially varying impacts of covariates across a study area and focuses attention on local variations. Given the potential of GWPR to guide decision-making, this study aimed to describe the geographical distribution of hysterectomy incidence for benign indications in women older than 15 years old (15+) at the municipal level in Wallonia (southern region of Belgium) and to analyze potential associations with socioeconomic factors ('Education/training', 'Income and purchasing power' and 'Health and care') influencing the use of this surgery. METHODS: We carried out an ecological study on data for women aged 15+ living in one of the 262 Walloon municipalities who underwent hysterectomies for benign indications between 2012 and 2014. We linked standardized hysterectomy rates to three municipal-level socioeconomic factors ('Education/training', 'Income and purchasing power' and 'Health and care'). Then, a Poisson regression model and a GWPR were applied to study the relationships between hysterectomy incidence and socioeconomic covariates in Wallonia. RESULTS: The hysterectomy rate varied across the region. The Poisson regression revealed a positive and significant association between the hysterectomy rate and 'Income and purchasing power', and a negative and significant association between hysterectomies and 'Health and care'. The same associations were seen in the GWPR model. The latter demonstrated that the association between hysterectomies and 'Education and training' ranged from negative to positive over the study area. CONCLUSIONS: Hysterectomy incidence was shown to have nonstationary relationships with socioeconomic factors. These results support the development of targeted interventions for a more appropriate use of this surgery.

Geographic and Sociodemographic Disparities in Cardiovascular Risk in Burkina Faso: Findings from a Nationwide Cross-Sectional Survey.

BACKGROUND: Cardiovascular disease (CVD) risk assessment is a critical step in the current approach to the primary prevention of CVD, particularly in low-income countries such as Burkina Faso. In this study, we aimed to assess the geographic and sociodemographic disparities of the ten-year cardiovascular risk in Burkina Faso. METHODS: We conducted a secondary analysis of the data from the first nationwide survey using the World Health Organization (WHO) STEPwise approach. Ten-year cardiovascular risk was determined using the WHO 2019 updated risk chart (WHO risk) as main outcome, and the Framingham risk score (FRS) and the Globorisk chart for secondary outcomes. We performed a modified Poisson regression model using a generalized estimating equation to examine the association between CVD risk and sociodemographic characteristics. RESULTS: A total of 3081 participants aged 30 to 64 years were included in this analysis. The overall age and sex-standardized mean of absolute ten-year cardiovascular risk assessed using the WHO risk chart was 2.5% (95% CI: 2.4-2.6), ranging from 2.3% (95% CI: 2.2-2.4) in Centre Est to 3.0% (95% CI: 2.8-3.2) in the Centre region. It was 4.6% (95% CI: 4.4-4.8) for FRS and 4.0% (95% CI: 3.8-4.1) for Globorisk. Regarding categorized CVD risk (absolute risk ≥10%), we found out that the age and sex-standardized prevalence of elevated risk was 1.7% (95% CI: 1.3-2.1) for WHO risk, 10.4% (95% CI: 9.6-11.2) for FRS, and 5.9% (95% CI: 5.1-6.6) for Globorisk. For all of the three risk scores, elevated CVD risk was associated with increasing age, men, higher education, urban residence, and health region (Centre). CONCLUSION: We found sociodemographic and geographic inequalities in the ten-year CVD risk in Burkina Faso regardless of risk score used. Therefore, population-wide interventions are needed to improve detection and management of adult in the higher CVD risk groups in Burkina Faso.

Prevalence of abdominal obesity and its association with cardiovascular risk among the adult population in Burkina Faso: findings from a nationwide cross-sectional study.

OBJECTIVE: The objective of this study is to determine the prevalence of abdominal obesity, its predictors and its association with cardiovascular risk among adults in Burkina Faso. DESIGN: We performed a secondary analysis of data from a national cross-sectional study, using WHO STEPwise approach. SETTING: The study was conducted in Burkina Faso, in all the 13 regions of the country. PARTICIPANTS: Our study involved 4308 adults of both sexes, aged between 25 and 64 years. PRIMARY AND SECONDARY OUTCOMES: Our primary outcome was abdominal obesity, which was defined using a cut-off point of waist circumference (WC) of ≥94 cm for men and ≥80 cm for women. The secondary outcome was very high WC (≥102 cm for men and ≥88 cm for women) (for whom weight management is required). RESULTS: The mean age of participants was 38.5±11.1 years. The age-standardised prevalence of abdominal obesity was 22.5% (95% CI 21.3% to 23.7%). This prevalence was 35.9% (95% CI 33.9% to 37.9%) among women and 5.2% (95% CI 4.3% to 6.2%) among men. In urban areas, the age-standardised prevalence of abdominal obesity was 42.8% (95% CI 39.9% to 45.7%) and 17.0% (95% CI 15.7% to 18.2%) in rural areas. The age-standardised prevalence of very high WC was 10.2% (95% CI 9.3% to 11.1%). The main predictors of abdominal obesity were being female, increased age, married status, high level of education and living in urban areas. Abdominal obesity was also significantly associated with high blood pressure (adjusted prevalence ratio (aPR): 1.30; 95% CI 1.14 to 1.47) and hypercholesterolaemia (aPR: 1.52; 95% CI 1.18 to 1.94). According to the combination matrix between body mass index and WC, 14.6% of the adult population in Burkina Faso had an increased cardiometabolic risk. CONCLUSION: Our study showed a high prevalence of abdominal obesity and a high proportion of adults who require weight management strategies to prevent cardiometabolic complications. Strategies to reduce the burden of abdominal obesity and very high WC should be considered by Burkina Faso's policy-makers.

Socioeconomic inequalities in curative healthcare-seeking for children under five before and after the free healthcare initiative in Sierra Leone: analysis of population-based survey data.

BACKGROUND: Socioeconomic inequalities between and within countries lead to disparities in the use of health services. These disparities could lead to child mortality in children under 5 years by depriving them of healthcare. Therefore, initiatives to remove healthcare fees such as the Free Healthcare Initiative (FHCI) adopted in Sierra Leone can contribute to reducing these inequities in healthcare-seeking for children. This study aimed to assess the socioeconomic inequalities in healthcare-seeking for children under 5 years of age before and after the implementation of the FHCI. METHODS: Data were included on 1207, 2815, 1633, and 1476 children under 5 years of age with fever from the 2008, 2013, 2016, and 2019 nationwide surveys, respectively. Concentration curves were drawn for the period before (2008) and after (2013-2019) the implementation of the FHCI to assess socioeconomic inequalities in healthcare-seeking. Finally, Erreyger's corrected concentration indices were calculated to understand the magnitude of these inequalities. RESULTS: Before the implementation of the FHCI, there were inequalities in healthcare-seeking for children under five (Erreyger's corrected concentration index (CI) = 0.168, standard error (SE) = 0.049; p < 0.001) in favor of the wealthy households. These inequalities decreased after the implementation of the FHCI (CI = 0.061, SE = 0.033; p = 0.06 in 2013, CI = 0.039, SE = 0.04; p = 0.32 in 2016, and CI = - 0.0005, SE = 0.362; p = 0.98 in 2019). Furthermore, before the implementation of the FHCI, a significant pro-rich inequality in the districts of Kenema (CI = 0.117, SE = 0.168, p = 0.021), Kono (CI = 0.175, SE = 0.078, p = 0.028) and Western Area Urban (CI = 0.070, SE = 0.032, p = 0.031) has been observed. After the implementation of the FHCI in 2019, these disparities were reduced, 11 of the 14 districts had a CI around the value of equality, and only in 2 districts the pro-rich inequality were significant (Western Area Urban (CI = 0.035, SE = 0.016, p = 0.039) and Western Area Rural (CI = 0.066, SE = 0.030, p = 0.027)). CONCLUSION: The results of this study demonstrated that socio-economic inequalities in healthcare-seeking for children have been considerably reduced after the FHCI in Sierra Leone. To further reduce these inequalities, policy actions can focus on the increase of availability of health services in the districts where the healthcare-seeking remained pro-rich.

Care-Seeking for Fever for Children Under the Age of Five Before and After the Free Healthcare Initiative in Burkina Faso: Evidence from Three Population-Based Surveys.

BACKGROUND: In 2016, a free healthcare policy (FHP) was implemented in Burkina Faso for children under the age of five. In our study, we aimed to determine the prevalence of care-seeking for a fever in children under the age of five before and after the implementation of the FHP and to analyze the determinants of not seeking care under the FHP. METHODS: The data of three nationally representative surveys were used to evaluate the trends of the prevalence of care-seeking. We performed a modified Poisson regression using a generalized estimating equation to determine the factors associated with not seeking care. RESULTS: The prevalence for care seeking increased from 57.5% (95% CI, 54.2-60.8) in 2014 to 72.3% (95% CI, 68.1-76.2) in 2017. Children from the poor quintile were less likely to seek care when compared to children from the poorest quintile (prevalence ratio (PR) = 0.7 (95% CI, 0.5-0.9)). Caregivers who did not have messages regarding malaria in the past six months were more likely not to seek care (PR = 0.8 (95% CI, 0.7-0.9)). Caregivers of children aged 36-59 months were more likely not to seek care compared to those aged <12 months (PR = 1.6 (95% CI, 1.2-2.1)). Children from the Boucle du Mouhoun region (PR = 1.9 (95% CI, 1.2-3.2)) and the Centre-Est region (PR = 1.9 (95% CI, 1.2-3.0)) were more likely not to seek care compared to children from the Sud Ouest region. CONCLUSION: Our study showed an increase in the prevalence of care-seeking after the implementation of the FHP. Even if this is encouraging, these findings highlight the critical importance of non-financial barriers to care-seeking. Maintaining FHP and tackling the barriers should be considered by policy makers to increase care-seeking.

Asymptomatic malaria and anaemia among pregnant women during high and low malaria transmission seasons in Burkina Faso: household-based cross-sectional surveys in Burkina Faso, 2013 and 2017.

BACKGROUND: Malaria in endemic countries is often asymptomatic during pregnancy, but it has substantial consequences for both the mother and her unborn baby. During pregnancy, anaemia is an important consequence of malaria infection. In Burkina Faso, the intensity of malaria varies according to the season, albeit the prevalence of malaria and anaemia as well as their risk factors, during high and low malaria transmission seasons is underexplored at the household level. METHODS: Data of 1751 pregnant women from October 2013 to March 2014 and 1931 pregnant women from April 2017 to June 2017 were drawn from two cross-sectional household surveys conducted in 24 health districts of Burkina Faso. Pregnant women were tested for malaria in their household after consenting. Asymptomatic carriage was defined as a positive result from malaria rapid diagnostic tests in the absence of clinical symptoms of malaria. Anaemia was defined as haemoglobin level less than 11 g/dL in the first and third trimester and less than 10.5 g/dL in the second trimester of pregnancy. RESULTS: Prevalence of asymptomatic malaria in pregnancy was estimated at 23.9% (95% CI 20.2-28.0) during the high transmission season (October-November) in 2013. During the low transmission season, it was 12.7% (95% CI 10.9-14.7) between December and March in 2013-2014 and halved (6.4%; 95% CI 5.3-7.6) between April and June 2017. Anaemia prevalence was estimated at 59.4% (95% CI 54.8-63.8) during the high transmission season in 2013. During the low transmission season, it was 50.6% (95% CI 47.7-53.4) between December and March 2013-2014 and 65.0% (95% CI 62.8-67.2) between April and June, 2017. CONCLUSION: This study revealed that the prevalence of malaria asymptomatic carriage and anaemia among pregnant women at the community level remain high throughout the year. Thus, more efforts are needed to increase prevention measures such as IPTp-SP coverage in order to reduce anaemia and contribute to preventing low birth weight and poor pregnancy outcomes.

Care-Seeking for Fever for Children Under the Age of Five Before and After the Free Healthcare Initiative in Burkina Faso: Evidence from Three Population-Based Surveys

: In 2016, a free healthcare policy (FHP) was implemented in Burkina Faso for children under the age of five. In our study, we aimed to determine the prevalence of careseeking for a fever in children under the age of five before and after the implementation of the FHP and to analyze the determinants of not seeking care under the FHP. Methods: The data of three nationally representative surveys were used to evaluate the trends of the prevalence of care-seeking. We performed a modified Poisson regression using a generalized estimating equation to determine the factors associated with not seeking care. Results: The prevalence for care seeking increased from 57.5% (95% CI, 54.2­60.8) in 2014 to 72.3% (95% CI, 68.1­76.2) in 2017. Children from the poor quintile were less likely to seek care when compared to children from the poorest quintile (prevalence ratio (PR) = 0.7 (95% CI, 0.5­0.9)). Caregivers who did not have messages regarding malaria in the past six months were more likely not to seek care (PR = 0.8 (95% CI, 0.7­0.9)). Caregivers of children aged 36­59 months were more likely not to seek care compared to those aged <12 months (PR = 1.6 (95% CI, 1.2­2.1)). Children from the Boucle du Mouhoun region (PR = 1.9 (95% CI, 1.2­3.2)) and the Centre-Est region (PR = 1.9 (95% CI, 1.2­3.0)) were more likely not to seek care compared to children from the Sud Ouest region. Conclusion: Our study showed an increase in the prevalence of care-seeking after the implementation of the FHP. Even if this is encouraging, these findings highlight the critical importance of non-financial barriers to care-seeking. Maintaining FHP and tackling the barriers should be considered by policy makers to increase care-seeking.

Malaria Case Fatality Rate among Children under Five in Burkina Faso: An Assessment of the Spatiotemporal Trends Following the Implementation of Control Programs.

Reducing the 2015 level of malaria mortality by 90% by 2030 is a goal set by the World Health Organization (WHO). In Burkina Faso, several malaria control programs proven to be effective were implemented over the last decade. In parallel, the progressive strengthening of the health surveillance system is generating valuable data, which represents a great opportunity for analyzing the trends in malaria burden and assessing the effect of these control programs. Complementary programs were rolled out at different time points and paces, and the present work aims at investigating both the spatial and temporal pattern of malaria case fatality rate (mCFR) by considering the effect of combining specific and unspecific malaria control programs. To this end, data on severe malaria cases and malaria deaths, aggregated at health district level between January 2013 and December 2018, were extracted from the national health data repository (ENDOS-BF). A Bayesian spatiotemporal zero-inflated Poisson model was fitted to quantify the strength of the association of malaria control programs with monthly mCFR trends at health district level. The model was adjusted for contextual variables. We found that monthly mCFR decreased from 2.0 (95% IC 1.9-2.1%) to 0.9 (95% IC 0.8-1.0%) deaths for 100 severe malaria cases in 2013 and 2018, respectively. Health districts with high mCFR were identified in the northern, northwestern and southwestern parts of the country. The availability of malaria rapid diagnosis tests (IRR: 0.54; CrI: 0.47, 0.62) and treatment (IRR: 0.50; CrI: 0.41, 0.61) were significantly associated with a reduction in the mCFR. The risk of dying from malaria was lower in the period after the free healthcare policy compared with the period before (IRR: 0.47; CrI: 0.38, 0.58). Our findings highlighted locations that are most in need of targeted interventions and the necessity to sustain and strengthen the launched health programs to further reduce the malaria deaths in Burkina Faso.

Effect of Free Healthcare Policy for Children under Five Years Old on the Incidence of Reported Malaria Cases in Burkina Faso by Bayesian Modelling: "Not only the Ears but also the Head of the Hippopotamus".

Burkina Faso has recently implemented an additional strategy, the free healthcare policy, to further improve maternal and child health. This policy targets children under five who bear the brunt of the malaria scourge. The effects of the free-of-charge healthcare were previously assessed in women but not in children. The present study aims at filling this gap by assessing the effect of this policy in children under five with a focus on the induced spatial and temporal changes in malaria morbidity. We used a Bayesian spatiotemporal negative binomial model to investigate the space-time variation in malaria incidence in relation to the implementation of the policy. The analysis relied on malaria routine surveillance data extracted from the national health data repository and spanning the period from January 2013 to December 2018. The model was adjusted for meteorological and contextual confounders. We found that the number of presumed and confirmed malaria cases per 1000 children per month increased between 2013 and 2018. We further found that the implementation of the free healthcare policy was significantly associated with a two-fold increase in the number of tested and confirmed malaria cases compared with the period before the policy rollout. This effect was, however, heterogeneous across the health districts. We attributed the rise in malaria incidence following the policy rollout to an increased use of health services combined with an increased availability of rapid tests and a higher compliance to the "test and treat" policy. The observed heterogeneity in the policy effect was attributed to parallel control interventions, some of which were rolled out at different paces and scales. Our findings call for a sustained and reinforced effort to test all suspected cases so that, alongside an improved case treatment, the true picture of the malaria scourge in children under five emerges clearly (see the hippopotamus almost entirely).

Spatial distribution and determinants of asymptomatic malaria risk among children under 5 years in 24 districts in Burkina Faso.

BACKGROUND: In malaria endemic countries, asymptomatic cases constitute an important reservoir of infections sustaining transmission. Estimating the burden of the asymptomatic population and identifying areas with elevated risk is important for malaria control in Burkina Faso. This study analysed the spatial distribution of asymptomatic malaria infection among children under 5 in 24 health districts in Burkina Faso and identified the determinants of this distribution. METHODS: The data used in this study were collected in a baseline survey on "evaluation of the impact of pay for performance on the quality of care" conducted in 24 health districts in Burkina Faso, between October 2013 and March 2014. This survey involved 7844 households and 1387 community health workers. A Bayesian hierarchical logistic model that included spatial dependence and covariates was implemented to identify the determinants of asymptomatic malaria infection. The posterior probability distribution of a parameter from the model was summarized using odds ratio (OR) and 95% credible interval (95% CI). RESULTS: The overall prevalence of asymptomatic malaria infection in children under 5 years of age was estimated at 38.2%. However, significant variation was observed between districts ranging from 11.1% in the district of Barsalgho to 77.8% in the district of Gaoua. Older children (48-59 vs < 6 months: OR: 6.79 [5.62, 8.22]), children from very poor households (Richest vs poorest: OR: 0.85 [0.74-0.96]), households located more than 5 km from a health facility (< 5 km vs  ≥ 5 km: OR: 1.14 [1.04-1.25]), in localities with inadequate number of nurses (< 3 vs ≥ 3: 0.72 [0.62, 0.82], from rural areas (OR: 1.67 [1.39-2.01]) and those surveyed in high transmission period of asymptomatic malaria (OR: 1.27 [1.10-1.46]) were most at risk for asymptomatic malaria infection. In addition, the spatial analysis identified the following nine districts that reported significantly higher risks: Batié, Boromo, Dano, Diébougou, Gaoua, Ouahigouya, Ouargaye, Sapouy and Toma. The district of Zabré reported the lowest risk. CONCLUSION: The analysis of spatial distribution of infectious reservoir allowed the identification of risk areas as well as the identification of individual and contextual factors. Such national spatial analysis should help to prioritize areas for increased malaria control activities.