BURKINA FASO LITERATURE REVIEW


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Burkina Faso Situation Analysis, The Population Council, African Alternatives No.4, March 1992

Quality of care in family planning programmes: a rapid assessment in Burkina Faso, Askew I., et al, Health Policy and Planning; 8(1):19-32, 1993

Introduction

The family planning program in Burkina Faso was established in 1985 in response to government recognition of family planning as an essential component of maternal and child health services. Through the Ministere de la Sante et de l’Action Sociale (MSAS), FP services are currently provided in 90 clinical service delivery points (SDP’s) distributed throughout the country’s thirty provinces. A Situation Analysis was undertaken by the Family Health Division of the MSAS an the Africa OR/TA Project with a view to examining Burkina Faso’s national family planning program. Out of the country’s 90 SDP’s, 53 were selected to make up a sample than was both easily accessible and representative.

Human and material resources

Infrastructure and equipment

The inventory of clinic facilities showed that the clinics’ infrastructure was adequate on the whole. However, some disparities were noted between the urban and rural clinics in terms of equipment. Almost a third of the provincial clinics lacked examination tables and three quarters of them lacked sterilizers. The absence of autoclaves and blood pressure gauges in a high proportion of clinics was a particular cause for concern. Moreover, where the equipment was present, it was usually not available exclusively for FP services, but was share with MCH service providers. Generally speaking, the waiting areas for clients at the clinics had functioning toilets, adequate seating and were protected from the sun and rain. In three-quarters of the clinics, the counseling and examination areas were reasonably private; however, in the other 25% (most which were in the provinces), clients being counseled were not always separated from those waiting. In only 70% of clinics was there a separate area for medical examinations.

Personnel

Of the 93 providers surveyed, the vast majority were midwives; only five physicians were found, all of them based in the cities. Although all were currently providing family planning services, 15% had no formal training in FP, and only half of those trained had received training in counseling. However, informal on-the-job training from experienced colleagues was cited as a common mode of compensating for the lack of structured training. Of the 53 clinics visited, 26 had only one staff member providing family planning, and of these eight had not received formal training.

IEC materials and activities

Information-education-communication (IEC) materials were not widely available, apart from posters, because their production was interrupted during the last two years and stocks have run out. Some clinics did have posters, but these were not hung up because pins or tape were not available. Most providers did not carry out IEC activities outside the clinic, although in 24 of the SDPs it was claimed that a health talk that included family planning was held at the clinic on a daily basis. It is worth noting, however, that 42% of clinics visited had at least one provider who included FP/IEC in their talks at community meetings, and 14% of the providers had given talks in schools. However, these outreach activities occurred mostly in the rural provinces. Of 502 clients interviewed who had heard about family planning (including both FP and MCH clients), 42% had first heard about FP from clinic staff (53% in rural areas), 27% from the media and 21% from their family. This suggests that the clinics and their staff are an important first source of information about FP, particularly in rural areas.

Logistics and supplies

Of the six methods provided by the programme, three are available in all clinics in the urban areas, the others to a lesser degree. Injectable contraceptives can only be provided by physicians, and this explains their virtual unavailability in rural clinics. Restocking contraceptives is done through an ordering system that requires orders to be placed when stocks reach a certain level; this approach was deemed satisfactory by the majority of providers.

Quality of care

Choice of methods

The programme in Burkina Faso offers primarily four methods-the pill, IUD, condoms and spermicides-although in come clinics injectables are provided. However, as with many ‘young’ family planning programmes, the dominant method is the pill (used by 66% of clients), with the IUD a distant second (23% of clients). Permanent methods are neither discussed nor, it seems, available. No training or equipment has been provided for sterilization services as it has not been seen, to date at least, as a priority by the Ministry. During observations of the 66 consultations with new clients, the observers felt that an appropriate choice of methods was discussed less than half the time, indicating that many women may not be aware of methods apart from the pill.

Information given to clients

The pill was discussed in 80% of consultations observed, and the IUD, spermicides and condom in only 40%. Among the clients who were given information about the pill, all of them were told how to use the method, but only 60% were told about contraindications, and less than half told of side-effects and how to manage them. This situation may have been exacerbated by the fact that virtually no counseling materials are currently available at the clinics. The only materials used were samples of contraceptives, and then only in 36% of consultations observed.

When asked afterwards, 24% of new clients said that they were partially, or not, satisfied with the information which they received. Allowing for the ‘courtesy bias’ which may influence responses to such questions, this figure probably underestimated the true level of dissatisfaction, which suggests that, overall, clients would appreciate more detailed information about the methods.

Competence of providers

The providers, most of whom were nurse-midwives, showed themselves to be technically competent when undertaking the medical counseling and examination procedures. In the majority of cases, the new clients’ medical history was checked and where equipment was available, their blood pressure and weight were recorded; 67% had a gynecological examination. During the exit interviews, however, 29% of new pill acceptors and 14% of continuing pill users could not give a correct explanation of how to use the method. These results again suggest that although medically competent, many providers need to ensure that their clients fully understand the instructions in method use they have been gives; their willingness and ability to communicate this information needs to be improved.

Client-provider relations

When observing the degree to which providers ascertained their clients’ needs, it was noted that in only half of the consultations were the clients’ reproductive intentions discussed, although their previous experiences and method preferences were assessed in two-thirds of the consultations although more typically in urban than rural areas.

Range of services

Integration of MCH and family planning services, if defined as their concurrent availability five days a week, was found to exist in all clinics in Ouagadougou, four of the eight clinics in Bobo-Dioulasso, and nine of the 32 clinics visited in the provinces. A previous operation research project in 1990 had already introduced an explicitly integrated approach in Ouagadougou, and these results show that it has bee sustained successfully and could probably be expanded to other clinics in the country.

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Etude Pour Contribuer a la Promotion de l’Utilization des Condoms par les Jeunes de Zones Urbaines et Rurales, Ministere de la Sante de l’Action Sociale et de la Famille et The Population Council, 1993

Since 1988, the government of Burkina Faso had adopted an overt and progressive approach towards the prevention of AIDS. In 1989, the National Committee in the Fight Against AIDS (CNLS) with l’Organisation Mondiale de la Sante (OMS) developed a plan for a period of three years to fight AIDS. In 1993, USAID/Burkina, The Population Council, GTZ and the Ministry of Health through the National AIDS Control Committee jointly carried out a qualitative study to help promote the use of condoms by youth in the formal sectors in rural and urban areas.

The results of focus groups indicated that young people were aware of STDs among which they classified AIDS with the peculiarity of incurable pathology. They defined AIDS as a "serious STD, a lethal one." AIDS symptoms were quite well known, apart from fever which remained a less known sign.

There were rumors about the risk factors, but the risk which was the best known by almost everybody was "sexual infidelity". False rumors were found about the origin of the disease, the risk of contamination by accidental contact with the AIDS patient (greeting him or eating with him...) and finally about sputum of the AIDS patient or HIV-positive individual. The notion of being HIV-positive was well known and the HIV-positive patient was considered "dangerous". The study population was familiar with the modes of transmission through sexual intercourse and blood products. However, here again there were rumors about the environment or the consumption of food, for instance, meat touched by an AIDS patient, and the transmission through insects such as mosquitos and flies.

Aids was considered a fatal incurable disease which provokes a range of various feelings among young people: fear, shame, pity and disdain. Nevertheless, the majority of people thought that those who died from AIDS deserve normal burial rites.

Preventive measures cited during the focus group discussions were "to avoid sexual infidelity" and to use condoms which is the "remedy" for AIDS. Preventive measures related to rumors such as "to serve food to the infected person alone" were also mentioned. Knowledge of the condom can be distinguished by those who knew it because they used it; those who knew it because they saw it ; and those who knew it because they had heard about it. Finally, in the informal sector, and mainly among girls, certain participants said that they had never heard about condoms.

Information sources preferred by youth remain health providers for both sectors, radio for the informal sector because it is accessible to everybody, and lastly movie shows. The condom marketing program (PROMACO) has been cited in provincial administrative towns. Condoms were sold everywhere, but there was not a selling center for youth of the informal sector in two of the four rural areas. The majority of youth found the costs of condoms affordable, but a minority thought that the price should be reduced or condoms should be distributed free.

The reason for condom utilizations by youth was determined by three elements: i) to avoid STDs and AIDS; ii) to avoid unwanted pregnancies mainly among girl users; iii) for curiosity and lack of confidence in the partner. Among the reasons given for the non-utilization of condoms, youths cited confidence in and faithfulness to the partner, non-enjoyment, and partner’s dislike or refusal.

Youths expected IEC campaigns to continue but wanted emphasis placed on the signs and severity of the disease, and demonstrations about how to use the condom. They wished that greater importance be given to film projections showing pictures of AIDS patients by indicating the evolution of the disease. Youths wished that particular attention be given to them: "think of us". The language used during IEC campaigns was often found to be non-understandable. Young people thought that there should be some talks about contraceptive benefits of condoms instead of talking only about its preventive aspect against AIDS/STDs. Some young people of the informal sector thought that IEC campaigns should involve youth leaders.

The types of environment which could be used to reach youths remained youth associations and sport clubs. Traditional and cultural ceremonies could be used for the informal sector. The best period for the informal sector is the dry season. As far as youths of the formal sector are concerned, professors in the scientific fields were resource persons to ensure sensitization. Furthermore, students have also expressed the wish to have a course on AIDS added to their school curriculum.

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Contexte Sociocultural et Problematique de la Prevention du SIDA en Afrique: Reflexions a partir du cas de la societe Mossi au Burkina Faso, Ouedraogo, Arouna, Medecin-chef du Service Psychiatrie, CHN Yalgado, Development et Sante, 1994.

On September 30, 1988, Burkina Faso had only 26 reported AIDS cases. By March 20, 1992 there were 1263 reported cases. There are observable behaviors, practices and beliefs of the Mossi society, the largest ethnic group in the country (48% of the total population) which expose people to HIV or facilitate its transmission.

The Mossi is a hierarchical society with the chief having absolute power. The head of the family has absolute power over the women and children. Polygamy is common. The Mossi describe their past as an earthly paradise with no AIDS. This magnificent past, along with the belief that ancestors can intervene to protect the health, allows a faulty perception of one’s risk of acquiring AIDS.

In addition, the cultural tradition of a widow marrying her husband’s younger brother appears to be a risk for HIV infection. If the husband has died of AIDS, this immediate remarriage allows the disease to be passed on. A further risk is the use of non-sterilized instruments used to perform genital mutilations and traditional vaccinations by scarification and the tradition of preparing cadavers without the use of gloves. Uncircumcised males and females are stigmatized and marginalized in Mossi society and thus circumcision is nearly universal among the Mossi people.

Serious obstacles to HIV prevention campaigns are erroneous beliefs about the modes of HIV transmission, the acculturated fatalistic attitude among youth that one contracts AIDS whether or not one takes precautions and the attitude that AIDS comes from somewhere else.

Children Take the Lead in Peer Education in Burkina Faso Villages

According to this article, only 29% of the population of Burkina Faso uses Health Care Services. Thus a health center is not the primary source of HIV/AIDS information. Plan International set up a project to train children as young as eight to communicate with adults about HIV/AIDS. The children were used at the villagers own request as being the best choice to act as health communicators. Children have an important role in West African society. They are often consulted during negotiations such as divorce. As ‘innocents’ they can talk about a taboo subject such as AIDS and sex without offending. Unlike the local health educator, children are in the village at all times.

Youths who were trained as communicators used objects in everyday life as teaching tools: dyes for blood, traditional floppy hats for the tips of condoms, a mat to illustrate unrolling of the condom. Youths were responsible for condom sales in their villages and were permitted to keep revenues

Presently this project has extended to 105 villages in 3 provinces. 1,495 village communicators have been trained, 590 of them youth and in the first 6 months of 1994, roughly 26,000 people were reached and 13,528 condoms were sold.

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Burkina Faso Family Planning Expansion Project; 1992 Baseline Community Study, prepared by Stella O. Babalola and Miriam Jato.

Overview

This study was conducted in May, 1992, in four of fifteen provinces targeted for IEC activities. The aim of the study was to obtain baseline information with respect to the target population’s knowledge, attitudes, and practice of family planning; exposure to, and understanding of the population logo; and perception of the population relative to health and social workers. A total of one thousand respondents (494 men and 506 women) were interviewed through a structured questionnaire.

Main Findings

A. Socio-economic characteristics

B. Awareness of Family Planning Methods

C. Family Planning Information

D. Family Planning Related Attitudes

E. Fertility Preferences

F. Perceptions of Health and Social Workers

G. Practice of Family Planning

H. Perception of the Family Planning Logo

Recommendations

1. Awareness of family planning is already very high; however, awareness can be increased among specific groups. Efforts should be made to increase awareness among those socio-economic groups which currently manifest relatively lower than average FP awareness: those with little or no education, Moslems, and those aged less than 20 years or more than 40 years. The use of the family planning was surprisingly high among those who had received basic literacy training; incorporating family planning and maternal and child health messages into a literacy campaign may be one avenue to explore. Enlisting the support of Islamic leaders, both at the local and national levels, may be vital to bringing this group into the program. Finally, both young people and older people need to be educated about family planning, either through established institutions or through the creations of an outreach program specifically designed for these two age groups. As delaying the first pregnancy is part of the Burkina Family Planning Strategy, the evidence of high levels of premarital sexual activity is particularly relevant. Further study may be necessary to determine the level of premarital sexual activity and to develop appropriate policy to promote the health and social well being of teens and young girls.

2. Awareness of family planning, and use of family planning were unexpectedly low in Yatenga. Based in this sample, Yatenga appears to have the lowest awareness of family planning; the overall findings for Yatenga were lower than expected, given that family planning service coverage has been strong in Yatenga.

Data has been verified, yet the findings remain suspect. One area of concern with the sample is the high representation of Moslems (92%). This should be checked with other available data to determine the representativeness of the sample, as Moslems in general had lower levels of awareness and use of family planning.

3. Although many people appear to know the Pill and the condom, relatively few people are aware of the other FP methods. Attention should generally focus on increasing the knowledge of the population with respect to modern methods. Potential clients should be made aware of the variety of possible surgical and non-surgical methods from which they could eventually choose. The fact that 85% of women currently using a modern method were using the pill suggests the possibility of an over-reliance on, or service-provider bias toward the pill; a situation analysis may be necessary to determine whether or not there is a serious problem. Training of health and social workers should emphasize the importance of client choice and the availability of a range of methods in order to increase the number of acceptors and improve continuation rates.

4. While almost 90% of respondents approved of family planning, only two-thirds believe that their partners approve. This indicates a substantial gap in communication between partners regarding the use of family planning. Even more telling is the fact that the proportion of those who have spoken with their spouses about family planning is nearly identical to that of those who believe their spouses approve.

Discussion of family planning and child spacing should be promoted among spouses, as an erroneous belief of a spouse’s disapproval may cause a potential contraceptor to eschew family planning.

5. One-fifth of the population failed to provide a definite response to the question on ideal family size, mainly because they felt that the decision was "up to God." This finding is very encouraging, given the improvement noted since the beginning of the family planning program in 1985. At that time, the majority of the population held this fatalistic attitude. This indicates that the majority of the population held this fatalistic attitude. This indicates that the majority now feel that they can and should determine how many children to have and when. The remaining fifth of the population should be viewed as a special hard-to-reach target group: such a fatalistic attitude is more prevalent among Moslems, married people, those with no formal education, and people aged more than 40 years. It may be necessary for program activities to aim at changing this negative attitude as it may eventually affect the decision to adopt contraception.

6. Although fertility preferences are towards smaller family sizes, many people still favor a family size of five or more children. This statement is particularly true outside of Kadiogo (Ouagadougou). It is also true of those with little or no education, and those aged more than 30 years. Program activities should therefore focus on promoting the health and economic benefits of child spacing, delaying first pregnancies, and discouraging late pregnancies, especially among the affected socia-economic groups.

7. While the majority of the respondents had listened to a talk on family planning and child spacing, few received specific information on modern contraceptives. This is a lost opportunity for familiarizing a large number of people with the variety of contraceptives, as well as their individual advantages. While most approved of the idea of family planning, many may still have fears regarding the loss of fertility after using modern methods. It is also an excellent opportunity to promote the more permanent methods among couples who do not want any more children. Efforts should be made to incorporate information on modern family planning methods into these talks.

8. The use of contraceptive methods is higher among men than among women. This is mainly because many unmarried men (47%) practice family planning. While the condom was the most-used method by both single and married men, single men were more likely to practice family planning. On the other hand, married men were twice as likely to report that their partners were using the Pill. Efforts should be intensified to promote the use of modern contraceptive methods among the population as a whole and to develop campaigns aimed specifically at both married women and married men. The women should be exposed to family planning information and counseling and antenatal and post-natal clinics. Family planning IEC campaigns should also be extended to markets and other public places where women are often found. Similar efforts should target the places where men are likely to be receptive to family planning information.

9. Compared with other women, the use of modern contraception is significant less prevalent among the women from Namentenga. Only 2 percent of them are using a modern method. Special program activities aimed at increasing prevalence should be targeted towards this province.

10. About two-thirds of the people not currently using family planning report intention to do so within the next year. Most of the current non-users who are not pregnant or desiring a child gave their reasons for non-use as lack of family planning information. This indicates not only a substantial number of potential users, but also the enormous need for an effective IEC strategy. An ongoing strategy of monitoring and evaluation of the IEC program is necessary to ensure that the target groups are getting the information they need.

11. A significant number of health and social workers are not using IEC materials. It is necessary to investigate the reasons for non-use of family planning IEC materials among health and social workers. Depending on the outcome of the investigation, health and social workers should be trained, retrained or encouraged to use IEC materials more often. Such IEC materials should not be limited to contraceptive samples alone, but should include print materials, video, and other electronic materials. If necessary, these materials should be promptly produced and distributed.

12. A significant number of respondents appear to have doubts about the abilities and intentions of social workers. It remains unclear from this study, however, whether these doubts are the result of inadequate training of social workers with regards to both technical and interpersonal skills. Due to the structure of the questionnaire, the large number who responded to questions on social workers with "I don’t know" skewed the results and the comparability of the answers to those regarding health workers. The data may simply indicate that few people are actually in contact with social workers, and therefore have had no opportunity to form an opinion. Further study is necessary to determine whether there is an actual problem with social workers before making recommendations to retrain them.

13. While the majority of respondents were aware of the National Family Planning Logo, the remaining of the symbol has not been firmly linked with family planning. Efforts should be made to improve the understanding of the logo among the population. In addition to maintaining ongoing promotional activities, new efforts should focus on associating the logo with child spacing and family planning. As larger materials such as posters and billboards are already in place, new promotional materials such as pins (currently popular in Burkina Faso) and small stickers should be produced and distributed. Use of these small and versatile items may contribute to an increase in interpersonal promotion of family planning, which in turn may contribute to general improvement in the understanding of the logo. Materials used by family planning counselors and service providers should also hear the logo. Items such as prescription books could be developed and distributed to health personnel. In additional, the logo should be displayed in chemists and other establishments (e.g., shops, supermarkets, etc.) likely to sell contraceptive devices.

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