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System-level determinants of immunization coverage disparities among health districts in Burkina Faso: a multiple case study.

ABSTRACT: BACKGROUND: Despite rapid and tangible progress in vaccine coverage and in premature mortality rates registered in sub-Saharan Africa, inequities to access remain firmly entrenched, large pockets of low vaccination coverage persist, and coverage often varies considerably across regions, districts, and health facilities' areas of responsibility. This paper focuses on system-related factors that can explain disparities in immunization coverage among districts in Burkina Faso. METHODS: A multiple-case study was conducted of six districts representative of different immunization trends and overall performance. A participative process that involved local experts and key actors led to a focus on key factors that could possibly determine the efficiency and efficacy of district vaccination services: occurrence of disease outbreaks and immunization days, overall district management performance, resources available for vaccination services, and institutional elements. The methodology, geared toward reconstructing the evolution of vaccine services performance from 2000 to 2006, is based on data from documents and from individual and group interviews in each of the six health districts. The process of interpreting results brought together the field personnel and the research team. RESULTS: The districts that perform best are those that assemble a set of favourable conditions. However, the leadership of the district medical officer (DMO) appears to be the main conduit and the rallying point for these conditions. Typically, strong leadership that is recognized by the field teams ensures smooth operation of the vaccination services, promotes the emergence of new initiatives and offers some protection against risks related to outbreaks of epidemics or supplementary activities that can hinder routine functioning. The same is true for the ability of nurse managers and their teams to cope with new situations (epidemics, shortages of certain stocks). CONCLUSION: The discourse on factors that determine the performance or breakdown of local health care systems in lower and middle income countries remains largely concentrated on technocratic and financial considerations, targeting institutional reforms, availability of resources, or accessibility of health services. The leadership role of those responsible for the district, and more broadly, of those we label "the human factor", in the performance of local health care systems is mentioned only marginally. This study shows that strong and committed leadership promotes an effective mobilization of teams and creates the conditions for good performance in districts, even when they have only limited access to supports provided by external partners. ABSTRACT IN FRENCH: See the full article online for a translation of this abstract in French.

SUBMITTER: Haddad S

PROVIDER: S-EPMC3226234 | biostudies-literature | 2009

REPOSITORIES: biostudies-literature

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System-level determinants of immunization coverage disparities among health districts in Burkina Faso: a multiple case study.

Haddad Slim S Bicaba Abel A Feletto Marta M Taminy Elie E Kabore Moussa M Ouédraogo Boubacar B Contreras Gisèle G Larocque Renée R Fournier Pierre P

BMC international health and human rights 20091014

<h4>Background</h4>Despite rapid and tangible progress in vaccine coverage and in premature mortality rates registered in sub-Saharan Africa, inequities to access remain firmly entrenched, large pockets of low vaccination coverage persist, and coverage often varies considerably across regions, districts, and health facilities' areas of responsibility. This paper focuses on system-related factors that can explain disparities in immunization coverage among districts in Burkina Faso.<h4>Methods</h4 ...[more]

PMID: 19828059

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Project description:BackgroundThe greatest challenge facing expanded programs on immunization in general, and in Burkina Faso in particular, lies in their capacity to achieve and sustain levels of immunization coverage that will ensure effective protection of children. This article aims to demonstrate that full immunization coverage of children, which is the primary indicator for monitoring national immunization programs, is sufficient neither to evaluate their performance adequately, nor to help identify the broad strategies that must be implemented to improve their performance. Other dimensions of performance, notably adherence to the vaccination schedule and the efficacy of the approaches used to reach all the children (targeting) must also be considered.MethodsThe study was carried out using data from surveys carried out in Burkina Faso: the 1993, 1998 and 2003 Demographic and Health Surveys and the 2003 national Survey of Immunization Coverage. Essentially, we described levels of immunization coverage and their trends according to the indicators considered. Performance differences are illustrated by amplitudes and maximum/minimum ratios.ResultsThe health regions' performances vary according to whether they are evaluated on the basis of full immunization coverage or vaccination status of children who have not completed their vaccinations. The health regions encompass a variety of realities, and efforts of substantially different intensity would be required to reach all the target populations.ConclusionDecision-making can be improved by integrating a tripartite view of performance that includes full immunization coverage, adherence to the vaccination schedule (timely coverage), and the status of children who are not fully vaccinated. With such an approach, interventions can be better targeted. It provides information on the quality and timeliness of vaccination and identifies the efforts required to meet the objectives of full immunization coverage. ABSTRACT IN FRENCH: See the full article online for a translation of this abstract in French.

Project description:BackgroundIn 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.MethodsThe 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).ResultsThe 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.ConclusionThe 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.

Project description:BackgroundBurkina Faso's immunization program has benefited regularly from national and international support. However, national immunization coverage has been irregular, decreasing from 34.7% in 1993 to 29.3% in 1998, and then increasing to 43.9% in 2003. Undoubtedly, a variety of factors contributed to this pattern. This study aims to identify both individual and systemic factors associated with complete vaccination in 1998 and 2003 and relate them to variations in national and international policies and strategies on vaccination of rural Burkinabé children aged 12-23 months.MethodsData from the 1998 and 2003 Demographic and Health Surveys and the Ministry of Health's 1997 and 2002 Statistical Yearbooks, as well as individual interviews with central and regional decision-makers and with field workers in Burkina's healthcare system, were used to carry out a multilevel study that included 805 children in 1998 and 1,360 children in 2003, aged 12-23 months, spread over 44 and 48 rural health districts respectively.ResultsIn rural areas, complete vaccination coverage went from 25.9% in 1998 to 41.2% in 2003. District resources had no significant effect on coverage and the impact of education declined over time. The factors that continued to have the greatest impact on coverage rates were poverty, with its various dimensions, and the utilization of other healthcare services. However, these factors do not explain the persistent differences in complete vaccination between districts. In 2003, despite a trend toward district homogenization, differences between health districts still accounted for a 7.4% variance in complete vaccination.ConclusionComplete vaccination coverage of children is improving in a context of worsening poverty. Education no longer represents an advantage in relation to vaccination. Continuity from prenatal care to institutional delivery creates a loyalty to healthcare services and is the most significant and stable explanatory factor associated with complete vaccination of children. Healthcare service utilization is the result of a dynamic process of interaction between communities and the healthcare system; understanding this process is the key to understanding better the factors underlying the complete vaccination of children.

Project description:A new serogroup A meningococcal conjugate vaccine (PsA-TT, MenAfriVac™) has been developed to combat devastating serogroup A Neisseria meningitis (MenA) epidemics in Africa. A mass immunization campaign targeting 1-29 year olds was conducted in Burkina Faso in December 2010. Protection of subsequent infant cohorts will be necessary through either introduction of PsA-TT into the routine Expanded Programme on Immunization (EPI) or periodic repeat mass vaccination campaigns.To inform future immunization policy for PsA-TT vaccination of infants through a comparison of PsA-TT campaign vaccination coverage and routine measles-containing vaccine (MCV) coverage in Burkina Faso.A national survey was conducted in Burkina Faso during December 17-27, 2011 using stratified cluster sampling to assess PsA-TT vaccine coverage achieved by the 2010 nationwide immunization campaign among 2-30 year olds and routine MCV coverage among 12-23 month olds. Coverage estimates and 95% Confidence Intervals (CI) were calculated, reasons for non-vaccination and methods of campaign communication were described, and a multivariable analysis for factors associated with vaccination was conducted.National overall PsA-TT campaign coverage was 95.9% (95% CI: 95.0-96.7) with coverage greater than 90% all 13 regions of Burkina Faso. National overall routine MCV coverage was 92.5% (95% CI: 90.5-94.1), but ranged from 75.3% to 95.3% by region. The primary predictor for PsA-TT vaccination among all age groups was a head of household informed of the campaign. PsA-TT vaccination was more likely in residents of rural settings, whereas MCV vaccination was more likely in residents of urban settings.Overall national vaccination rates in Burkina Faso were similar for PsA-TT and MCV vaccine. The regions with MCV coverage below targets may be at risk for sub-optimal vaccination coverage if PsA-TT is introduced in EPI. These results highlight the need for assessments of routine vaccination coverage to guide PsA-TT immunization policy in meningitis belt countries.

Project description:BackgroundThe Expanded Program on Immunization (EPI) is still in need of improvement. In Burkina Faso in 2003, for example, the Nouna health district had an immunization coverage rate of 31.5%, compared to the national rate of 52%. This study identifies specific factors associated with immunization status in Nouna health district in order to advance improved intervention strategies in this district and in those with similar environmental and social contexts.MethodsA cross-sectional study was undertaken in 41 rural communities and one semi-urban area (urban in the text). Data on 476 children aged 12 to 23 months were analyzed from a representative sample of 489, drawn from the Nouna Health Research Centre's Demographic Surveillance System (DSS) database. The vaccination history of these children was examined. The relationships between their immunization status and social, economic and various contextual variables associated with their parents and households were assessed using Chi square test, Pearson correlation and logistic regression.ResultsThe total immunization coverage was 50.2% (CI, 45.71; 54.69). Parental knowledge of the preventive value of immunization was positively related to complete immunization status (p = 0.03) in rural areas. Children of parents who reported a perception of communication problems surrounding immunization had a lower immunization coverage rate (p < 0.001). No distance related difference exists in terms of complete immunization coverage within villages and between villages outside the site of the health centres. Children of non-educated fathers in rural areas have higher rates of complete immunization coverage than those in the urban area (p = 0.028). Good communication about immunization and the importance of availability of immunization booklets, as well as economic and religious factors appear to positively affect children's immunization status.ConclusionVaccination sites in remote areas are intended to provide a greater opportunity for children to access vaccination services. These efforts, however, are often hampered by the poor economic conditions of households and insufficient communication and knowledge regarding immunization issues. While comprehensive communication may improve understanding about immunization, it is necessary that local interventions also take into account religious specificities and critical economic periods. Particular approaches that take into consideration these distinctions need to be applied in both rural and urban settings. ABSTRACT IN FRENCH: See the full article online for a translation of this abstract in French.

Project description:BackgroundInvestigating malaria transmission dynamics is essential to inform policy decision making. Whether multiplicity of infection (MOI) dynamic from individual infections could be a reliable malaria metric in high transmission settings with marked variation in seasons of malaria transmission has been poorly assessed. This study aimed at investigating factors driving Plasmodium falciparum MOI and genetic diversity in a hyperendemic area of Burkina Faso.MethodsBlood samples collected from a pharmacovigilance trial were used for polymerase chain reaction genotyping of the merozoite surface proteins 1 and 2. MOI was defined as the number of distinct parasite genotypes co-existing within a particular infection. Monthly rainfall data were obtained from satellite data of the Global Precipitation Measurement Database while monthly malaria incidence aggregated data were extracted from District Health Information Software 2 medical data of the Center-West health regional direction.ResultsIn the study area, infected people harboured an average of 2.732 (± 0.056) different parasite genotypes. A significant correlation between the monthly MOI and the monthly malaria incidence was observed, suggesting that MOI could be a good predictor of transmission intensity. A strong effect of season on MOI was observed, with infected patients harbouring higher number of parasite genotypes during the rainy season as compared to the dry season. There was a negative relationship between MOI and host age. In addition, MOI decreased with increasing parasite densities, suggesting that there was a within-host competition among co-infecting genetically distinct P. falciparum variants. Each allelic family of the msp1 and msp2 genes was present all year round with no significant monthly fluctuation.ConclusionsIn high malaria endemic settings with marked variation in seasons of malaria transmission, MOI represents an appropriate malaria metric which provides useful information about the longitudinal changes in malaria transmission in a given area. Besides transmission season, patient age and parasite density are important factors to consider for better understanding of variations in MOI. All allelic families of msp1 and msp2 genes were found in both dry and rainy season. The approach offers the opportunity of translating genotyping data into relevant epidemiological information for malaria control.

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System-level determinants of immunization coverage disparities among health districts in Burkina Faso: a multiple case study.

Publications

System-level determinants of immunization coverage disparities among health districts in Burkina Faso: a multiple case study.

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