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Contextual factors as a key to understanding the heterogeneity of effects of a maternal health policy in Burkina Faso?

ABSTRACT: Burkina Faso implemented a national subsidy for emergency obstetric and neonatal care (EmONC) covering 80% of the cost of normal childbirth in public health facilities. The objective was to increase coverage of facility-based deliveries. After implementation of the EmONC policy, coverage increased across the country, but disparities were observed between districts and between primary healthcare centres (PHC). To understand the variation in coverage, we assessed the contextual factors and the implementation of EmONC in six PHCs in a district. We conducted a contrasted multiple case study. We interviewed women (n = 71), traditional birth attendants (n = 7), clinic management committees (n = 11), and health workers and district health managers (n = 26). Focus groups (n = 62) were conducted within communities. Observations were carried out in the six PHCs. Implementation was nearly homogeneous in the six PHCs but the contexts and human factors appeared to explain the variations observed on the coverage of facility-based deliveries. In the PHCs of Nogo and Tara, the immediate increase in coverage was attributed to health workers' leadership in creatively promoting facility-based deliveries and strengthening relationships of trust with communities, users' positive perceptions of quality of care and the arrival of female professional staff. The change of healthcare team at Iata's PHC and a penalty fee imposed for home births in Belem may have caused the delayed effects there. Finally, the unchanged coverage in the PHCs of Fati and Mata was likely due to lack of promotion of facility-based deliveries, users' negative perceptions of quality of care, and conflicts between health workers and users. Before implementation, decision-makers should perform pilot studies to adapt policies according to contexts and human factors.

SUBMITTER: Belaid L

PROVIDER: S-EPMC4353895 | biostudies-other | 2015 Apr

REPOSITORIES: biostudies-other

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Contextual factors as a key to understanding the heterogeneity of effects of a maternal health policy in Burkina Faso?

Belaid Loubna L Ridde Valéry V

Health policy and planning 20140314 3

Burkina Faso implemented a national subsidy for emergency obstetric and neonatal care (EmONC) covering 80% of the cost of normal childbirth in public health facilities. The objective was to increase coverage of facility-based deliveries. After implementation of the EmONC policy, coverage increased across the country, but disparities were observed between districts and between primary healthcare centres (PHC). To understand the variation in coverage, we assessed the contextual factors and the imp ...[more]

PMID: 24633914

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Project description:BACKGROUND: This methodological article is based on a health policy research project conducted in Burkina Faso (West Africa). Concept mapping (CM) was used as a research method to understand the local views of equity among stakeholders, who were concerned by the health policy under consideration. While this technique has been used in North America and elsewhere, to our knowledge it has not yet been applied in Africa in any vernacular language. Its application raises many issues and certain methodological limitations. Our objective in this article is to present its use in this particular context, and to share a number of methodological observations on the subject. METHODS: Two CMs were done among two different groups of local stakeholders following four steps: generating ideas, structuring the ideas, computing maps using multidimensional scaling and cluster analysis methods, and interpreting maps. Fifteen nurses were invited to take part in the study, all of whom had undergone training on health policies. Of these, nine nurses (60%) ultimately attended the two-day meeting, conducted in French. Of 45 members of village health committees who attended training on health policies, only eight were literate in the local language (Moore). Seven of these (88%) came to the meeting. RESULTS: The local perception of equity seems close to the egalitarian model. The actors are not ready to compromise social stability and peace for the benefit of the worst-off. The discussion on the methodological limitations of CM raises the limitations of asking a single question in Moore and the challenge of translating a concept as complex as equity. While the translation of equity into Moore undoubtedly oriented the discussions toward social relations, we believe that, in the context of this study, the open-ended question concerning social justice has a threefold relevance. At the same time, those limitations were transformed into strengths. We understand that it was essential to resort to the focus group approach to explore deeply a complex subject such as equity, which became, after the two CMs, one of the important topics of the research. CONCLUSION: Using this technique in a new context was not the easiest thing to do. Nevertheless, contrary to what local organizers thought when we explained to them this "crazy" idea of applying the technique in Moore with peasants, we believe we have shown that it was feasible, even with persons not literate in French.

Project description:ContextThe person-centred approach (PCA) is a promising avenue for care improvement. However, health professionals in Burkina Faso (hereafter referred to as caregivers) seem unprepared for taking into consideration patients' preferences and values in the context of healthcare provision.ObjectiveTo understand the meaning attributed to PCA in the Burkina Faso context of care and to identify the challenges related to its adoption from the perspective of caregivers and women service users (hereafter referred to as patients).MethodsAn ethnographic qualitative research design was used in this study. We conducted 31 semi-directed interviews with caregivers and patients from Koudougou (Burkina Faso) healthcare facilities. We also carried out direct observation of consultations. Data thematic analyses are based on the person-centred approach analysis framework.ResultsAccording to the caregivers and patients interviewed, the PCA in maternal and child healthcare in Burkina Faso includes the following five components used in our analytical framework: i) pregnancy follow-up consultations extend beyond examining physical health issues (biopsychosocial component), ii) healthcare professionals' mood affects the caregiver-patient relationship as well as care delivery (the healthcare professional as a person), iii) patients expect to be well received, listened to, and respected (the patient as a person), iv) healthcare professionals first acknowledge that both themselves and patients have power, rights but also responsibilities (sharing power, rights and responsibilities of professionals and patients), and v) healthcare professionals who are open to involving patients in decision-making about their care and patients asking to have a say in the organization of services (therapeutic alliance). Implementing each of these themes comes with challenges, such as i) talking about health problems in the presence of other women, especially those related to sexuality, even though they are common to parturient women (biopsychosocial component); ii) offering psychotherapy to healthcare professionals (healthcare professional as a person); iii) taking into consideration patients' cultural and linguistic differences (the patient as a person); iv) raising awareness among patients about their right to ask questions and healthcare professionals' duty to answer them (sharing power, and rights and responsibilities of professionals and patients); v) accepting the presence of birth attendants while avoiding traditional practices that are contrary to scientific recommendations (therapeutic alliance).ConclusionDespite some context-specific particularities, the PCA is not new in the context of health care in Burkina Faso. However, its implementation can pose a number of challenges. There is a need to train healthcare professionals with a view to being sensitive to these particularities. This may also require organizational adjustments so as to create the physical and sociocultural environments that are conducive to taking into account the patient's perspective.

Project description:BACKGROUND:Over the past 15 years, scaling up of cost effective interventions resulted in a remarkable decline of under-five mortality rates (U5MR) in sub-Saharan Africa. However, the reduction shows considerable heterogeneity. We estimated the association of child, maternal, and household interventions with U5MR in Burkina Faso at national and subnational levels and identified the regions with least effective interventions. METHODS:Data on health-related interventions and U5MR were extracted from the Burkina Faso Demographic and Health Survey (DHS) 2010. Bayesian geostatistical proportional hazards models with a Weibull baseline hazard were fitted on the mortality outcome. Spatially varying coefficients were considered to assess the geographical variation in the association of the health interventions with U5MR. The analyses were adjusted for child, maternal, and household characteristics, as well as climatic and environmental factors. FINDINGS:The average U5MR was as high as 128 per 1000 ranging from 81 (region of Centre-Est) to 223 (region of Sahel). At national level, DPT3 immunization and baby post-natal check within 24 hours after birth had the most important association with U5MR (hazard rates ratio (HRR) = 0.89, 95% Bayesian credible interval (BCI): 0.86-0.98 and HRR = 0.89, 95% BCI: 0.86-0.92, respectively). At sub-national level, the most effective interventions are the skilled birth attendance, and improved drinking water, followed by baby post-natal check within 24 hours after birth, vitamin A supplementation, antenatal care visit and all-antigens immunization (including BCG, Polio3, DPT3, and measles immunization). Centre-Est, Sahel, and Sud-Ouest were the regions with the highest number of effective interventions. There was no intervention that had a statistically important association with child survival in the region of Hauts Bassins. INTERPRETATION:The geographical variation in the magnitude and statistical importance of the association between health interventions and U5MR raises the need to deliver and reinforce health interventions at a more granular level. Priority interventions are DPT3 immunization, skilled birth attendance, baby post-natal visits in the regions of Sud-Ouest, Sahel, and Hauts Bassins, respectively. Our methodology could be applied to other national surveys, as it allows an incisive, data-driven and specific decision-making approach to optimize the allocation of health interventions at subnational level.

Project description:INTRODUCTION:In Africa, a majority of women bring their infant to health services for immunization, but few are checked in the postpartum (PP) period. The Missed opportunities for maternal and infant health (MOMI) EU-funded project has implemented a package of interventions at community and facility levels to uptake maternal and infant postpartum care (PPC). One of these interventions is the integration of maternal PPC in child clinics and infant immunization services, which proved to be successful for improving maternal and infant PPC. AIM:Taking stock of the progress achieved in terms of PPC with the implementation of the interventions, this paper assesses the economic cost of maternal PPC services, for health services and households, before and after the project start in Kaya health district (Burkina Faso). METHODS:PPC costs to health services are estimated using secondary data on personnel and infrastructure and primary data on time allocation. Data from two household surveys collected before and after one year intervention among mothers within one year PP are used to estimate the household cost of maternal PPC visits. We also compare PPC costs for households and health services with or without integration. We focus on the costs of the PPC intervention at days 6-10 that was most successful. RESULTS:The average unit cost of health services for days 6-10 maternal PPC decreased from 4.6 USD before the intervention in 2013 (Jan-June) to 3.5 USD after the intervention implementation in 2014. Maternal PPC utilization increased with the implementation of the interventions but so did days 6-10 household mean costs. Similarly, the household costs increased with the integration of maternal PPC to BCG immunization. CONCLUSION:In the context of growing reproductive health expenditures from many funding sources in Burkina Faso, the uptake of maternal PPC led to a cost reduction, as shown for days 6-10, at health services level. Further research should determine whether the increase in costs for households would be deterrent to the use of integrated maternal and infant PPC.

Project description:Poverty is known as an important determinant of health, but empirical data are still missing on the relationships between poverty, other adverse living conditions, and psychological distress, particularly in low-income countries. This study aimed to assess mental health needs and psychological distress among the poorest in rural settings in Burkina Faso where food security and access to water, electricity, schooling, and healthcare are limited.We randomly selected 2000 individuals previously identified as indigents by a community-targeting process. Interviewers visited participants (n = 1652) in their homes and completed a questionnaire on mental health variables that included presence and intensity of anxious, depressive, psychotic, and aggressive symptoms, as well as level of psychological distress. Descriptive statistics, Spearman correlations, and logistic regressions were performed.In all, 40.2% of the sample reported 10 or more anxious/depressive symptoms in the past 30 days, and 25.5% reported having experienced at least one psychotic symptom over their lifetime, 65.6% of whom had had those symptoms for many years. The number of anxious and depressive symptoms was significantly associated with the level of psychological distress (r = 0.423, p < .001). Predictors of distress level included: poor health condition (F(1) = 23.743, p <. 001), being a woman (F(1) = 43.926, p < .001), not having any income (F(1) = 16.185, p < .001), having begged for food in the past 30 days (F(1) = 12.387, p < .001), being illiterate, and being older (F(1) = 21.487, p < .001). Approximately one third of respondents reporting anxious/depressive or psychotic symptoms (28.2 and 30.0%, respectively) had not talked about their symptoms to anyone in their social network.These results suggest alarmingly high levels of psychological distress and reported symptoms among the poorest in rural settings in Burkina Faso, which can be explained by their difficult living conditions. However, these results must be interpreted from a transcultural perspective to avoid decontextualized misinterpretations. Ethnographic works are needed to document the larger context within which these distress results can be analyzed.

Project description:BackgroundAlthough the relationship between self-rated health (SRH) and physical and mental health is well documented in developed countries, very few studies have analyzed this association in the developing world, particularly in Africa. In this study, we examine the associations of SRH with measures of physical and mental health (chronic diseases, functional limitations, and depression) among adults in Ouagadougou, Burkina Faso, and how these associations vary by sex, age, and education level.MethodsThis study was based on 2195 individuals aged 15 years or older who participated in a cross-sectional interviewer-administered health survey conducted in 2010 in areas of the Ouagadougou Health and Demographic Surveillance System. Logistic regression models were used to analyze the associations of poor SRH with chronic diseases, functional limitations, and depression, first in the whole sample and then stratified by sex, age, and education level.ResultsPoor SRH was strongly correlated with chronic diseases and functional limitations, but not with depression, suggesting that in this context, physical health probably makes up most of people's perceptions of their health status. The effect of functional limitations on poor SRH increased with age, probably because the ability to circumvent or compensate for a disability diminishes with age. The effect of functional limitations was also stronger among the least educated, probably because physical integrity is more important for people who depend on it for their livelihood. In contrast, the effect of chronic diseases appeared to decrease with age. No variation by sex was observed in the associations of SRH with chronic diseases, functional limitations, or depression.ConclusionsOur findings suggest that different subpopulations delineated by age and education level weight the components of health differently in their self-rated health in Ouagadougou, Burkina Faso. In-depth studies are needed to understand why and how these groups do so.

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Contextual factors as a key to understanding the heterogeneity of effects of a maternal health policy in Burkina Faso?

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Contextual factors as a key to understanding the heterogeneity of effects of a maternal health policy in Burkina Faso?

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