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Background Adolescents are increasingly aware of the treats of climate change and encouraged to take part in environmental actions. However, the current understanding climate anxiety adolescents is sparse. This study establishes the characteristics of adolescents who experience functional impairments induced by climate anxiety and who adopt pro-environment behaviours. It also characterizes the association between climate anxiety, feelings of self-efficacy and environmental actions. Methods 2 379) from 113 schools in Quebec answered questions about climate anxiety, self-efficacy, behavioural engagement and several indicators of wellbeing. Data were analysed using poisson regressions adjusted for potential confounders (age, gender, school type, material deprivation, etc). Results More than one in ten adolescents (11%) reported that thinking about climate change makes it difficult to sleep or interferes with their ability to get work or assignments done. Only 35% of adolescents believed that they can do something to address the problem and 44% tried to reduce their behaviors that contribute to climate change. Adolescents who are boys and who are less anxious were less preoccupied and involved in the fight against climate change. Teenagers from less affluent families were more concerned, but not more engaged. Those with a good relationship with their family and strong school connectedness were both less concerned and more involved in the fight against climate change. Adolescents who felt they can do something about climate change were more likely to try to reduce behaviors that contribute to climate change. Conclusion The findings are useful to identify and support vulnerable groups that are more likely to experience functional impairments due to climate anxiety. The feeling of climate self-efficacy was not well developed among some groups of adolescents. Improving the youth’s beliefs in their capacity to help address the climate change may be a key strategy to promote pro-environmental actions. As the threat of climate change increases, it will be important to follow the evolution of climate anxiety and engagement amongst adolescents.

Background Adolescence is a critical period for vaping onset. The purpose of this article was to examine the effect of the early stages of the COVID-19 pandemic period on youth vaping. Methods We used 3-year linked data from the COMPASS study, including 7585 Canadian (Quebec, Ontario) adolescents from which 1949 completed all three survey waves (pre-COVID-19 [2018, 2019] and online [2020] during the early pandemic period [May–July 2020]) and provided vaping data. Structural equation modeling (SEM) and difference-in-difference (DD) models were used to estimate pre-COVID-19 to initial COVID-19 pandemic period change (2019–2020) in vaping (monthly, weekly, daily) compared with 2018–2019 change to adjust for age-related effects. Models were adjusted for age of entry into the cohort and sociodemographic characteristics. Results In the SEM and DD models, the proportion of youth who were monthly and weekly vaping increased from 2018 to 2019 but decreased from 2019 to 2020; daily vaping increased across all waves. However, for all vaping outcomes modeled, the expected increases from the pre-COVID-19 wave (2019) to the initial COVID-19 period wave (2020) were lesser relative to the changes seen across the 2018 to 2019 waves. Conclusion The early stages of the COVID-19 pandemic period appear to be associated with a reduction in the proportion of youth who were monthly and weekly vapers in our adjusted longitudinal models. While daily vaping increased over this same period of time, the magnitude of the increase in our adjusted longitudinal models appears attenuated by the early stages of the pandemic. Implications This large prospective study of youth that included pre-pandemic data is unique in that we were able to identify that the early stages of the COVID-19 pandemic period was associated with a reduction in the proportion of youth who were monthly and weekly vapers in our adjusted longitudinal models. Conversely, the proportion of youth who were daily vaping increased over this same period of time, but the magnitude of the increase appears smaller than expected during the early stages of the pandemic in our adjusted longitudinal models. This study provides novel robust evidence that the patterns of vaping most aligned with onset and progression (i.e., monthly and weekly use) appear attenuated during the initial pandemic period.

Understanding risky sexual behaviors among adolescents is key in efforts devoted to reducing the health burden related to sexually transmitted infections and unintended or unplanned pregnancies. The aims of this study were to understand the association between number of lifetime sexual partners and time since sexual debut (TSSD) among adolescents and to determine whether sex modified this association. Data were drawn from the 2018-2019 COMPASS-Quebec study, a cohort study conducted in secondary schools in the province of Quebec, Canada. Of 18,467 respondents aged 14 years and older, 6991 (37.9%; mean age 15.3) reported consensual sexual intercourse and answered questions on their age at sexual initiation and number of lifetime sexual partners. Multilevel Poisson regressions with robust standard errors were estimated to adjust for covariates and produce adjusted group mean differences. The adjusted mean number of lifetime sexual partners ranged from 1.5 for those who had recently begun sexual activity ( 12 months) to 4.0 for those who had been active for 35 months, an average rise of about 0.6 per year. Females-to-males adjusted mean differences showed that males reported more sexual partners than females at all time points, but the differences were only significant at the shorter ( 12 months) and longer ( 35 months) time spans. This study highlights the importance of taking into account TSSD when using and interpreting the number of lifetime sexual partners as risky sexual behavior among adolescents. Sex did not have a significant modifying effect on the relationship between number of lifetime sexual partners and TSSD.

Introduction La présente étude avait pour objectifs d’explorer dans quelle mesure les adolescents ont adopté des mesures préventives contre la COVID-19 au cours des premiers mois de la pandémie et de comprendre leur adoption par l’examen de facteurs indépendants liés à l’adoption et par la détermination de la puissance de ces facteurs, en particulier parmi les sous-groupes qui ne sont pas censés être les premiers à adopter de telles mesures. Méthodes Les analyses portent sur des données recueillies au printemps 2020 auprès de 29 écoles secondaires de l’est du Québec qui ont participé à l’étude COMPASS. Les participants (n = 6 052) ont déclaré eux-mêmes leurs connaissances, leur perception du risque et les pratiques de prévention à adopter dans le contexte de la pandémie de COVID-19. Les données ont été analysées à l’aide de modèles d’équation structurelle fondés sur le sexe et le niveau d’anxiété. Résultats La majorité des répondants ont déclaré avoir adopté les mesures préventives recommandées contre la COVID-19. Les résultats ont montré trois voies menant à l’adoption de ces mesures par les adolescents : les connaissances sur la pandémie, la perception du risque lié à la COVID-19 et, en particulier, les discussions avec les proches au sujet des mesures préventives et de ce qu’il faut faire en cas d’infection. Conclusion Même si la plupart des participants adolescents à cette étude ont semblé se conformer aux mesures préventives contre la COVID-19, des facteurs comme les discussions avec les proches émergent en tant qu’éléments à favoriser pour améliorer l’adoption des mesures préventives par les adolescents.

Background Recent studies suggest that the risk of SARS-CoV-2 infection may be greater in more densely populated areas and in cities with a higher proportion of persons who are poor, immigrant, or essential workers. This study examines spatial inequalities in SARS-CoV-2 exposure in a health region of the province of Quebec in Canada. Methods The study was conducted on the 1206 Canadian census dissemination areas in the Capitale-Nationale region of the province of Quebec. The observation period was 21 months (March 2020 to November 2021). The number of cases reported daily in each dissemination area was identified from available administrative databases. The magnitude of inequalities was estimated using Gini and Foster-Greer-Thorbecke (FGT) indices. The association between transmission and socioeconomic deprivation was identified based on the concentration of transmission in socially disadvantaged areas and on nonparametric regressions relating the cumulative incidence rate by area to ecological indicators of spatial disadvantage. Quantification of the association between median family income and degree of exposure of dissemination areas was supplemented by an ordered probit multiple regression model. Results Spatial disparities were elevated (Gini = 0.265; 95% CI [0.251, 0.279]). The spread was more limited in the less densely populated areas of the Quebec City agglomeration and outlying municipalities. The mean cumulative incidence in the subsample made up of the areas most exposed to the pandemic was 0.093. The spread of the epidemic was concentrated in the most disadvantaged areas, especially in the densely populated areas. Socioeconomic inequality appeared early and increased with each successive pandemic wave. The models showed that areas with economically disadvantaged populations were three times more likely to be among the areas at highest risk for COVID-19 (RR = 3.55; 95% CI [2.02, 5.08]). In contrast, areas with a higher income population (fifth quintile) were two times less likely to be among the most exposed areas (RR = 0.52; 95% CI [0.32, 0.72]). Conclusion As with the H1N1 pandemics of 1918 and 2009, the SARS-CoV-2 pandemic revealed social vulnerabilities. Further research is needed to explore the various manifestations of social inequality in relation to the pandemic.

IntroductionAlthough many studies have examined the associations between growth problems in infancy and age at school entry, grade repetition, school dropout and schooling level in developing country, no synthesis of the evidence has been conducted. We aim to review evidence of the effects of stunting, or height-for-age, on schooling level and schooling trajectories, defined as the combination of school entry age, grade repetition, and school dropouts.MethodsWe conducted a systematic review of studies (last update March 20, 2021) estimating that estimate the association between stunting, or height-for-age, and at least one component of the school trajectory, or schooling level, using five databases (PubMed, Embase, Education Resources Information Center (ERIC), Web of Science and PsycINFO). Study selection and data extraction were performed by two independent reviewers. Pooled effects were calculated using the generic inverse variance weighting random effect model. The studies’ risk of bias was assessed using the ROBINS-I tool for non-randomized studies.ResultsWe screened 3944 records by titles and abstracts and retained 16 for inclusion in the qualitative and meta-analysis. Meta-analysis showed that an increase in height-for-age leads to an increase in early enrollment [OR: 1.34 (95% CI: 1.07; 1.67)], a reduction in late enrollment [OR: 0.63 (95% CI: 0.51; 0.78)], an increase in schooling level [MD: 0.24 (95% CI: 0.14; 0.34)], and a reduction of school overage [OR: 0.79 (95% CI: 0.70; 0.90)]. The odds of grade repetition increased by 59% (OR = 1.59; 95% CI: 1.18; 2.14) for stunted children compared to those with no stunting.ConclusionsThis review suggests that stunting in childhood might lead to a delay in school enrollment, grade repetition, school dropout, and low schooling levels in developing countries. Future research should evaluate the effect of stunting on academic trajectories in the same population and explore the potential modification effect of socioeconomic status. The current findings suggest that policy makers need to work more to prevent stunting and to include health issues in educational policies.Systematic review registration: PROSPERO CRD42020198346

We developed and validated an 8-item prognostic tool to identify youth at risk of initiating frequent (i.e., at least weekly) cannabis use in the next year. The tool, which aims to identify youth who would benefit most from clinician intervention, can be completed by the patient or clinician using a computer or smart phone application prior to or during a clinic visit. Methodological challenges in developing the tool included selecting a parsimonious model from a set of correlated predictors with missing data. We implemented Bach’s bolasso algorithm which combines lasso with bootstrap and investigated the performance of the prognostic tool in new data collected in a different time period (temporal validation) and in another location (geographic validation). The tool showed adequate discrimination abilities, as reflected by a c-statistic above 0.8, in both validation samples. Most predictors selected into the tool pertained to substance use including use of cigarettes, e-cigarettes, alcohol and energy drinks mixed with alcohol, but not to mental or physical health.

Background Seasonal malaria chemoprevention (SMC) relies on community health workers to distribute drugs. This study assessed: (1) the capacity of community-based distributors (CBDs) at the start and end of a campaign and from one campaign to another after training or refresher courses before each round; (2) to what extent CBDs’ experience over several campaigns contributed to measurable increase in their capacities; and (3) to what extent the training and experience of committed CBDs helped the less productive to catch up. Methods A longitudinal analysis was conducted in one Burkina Faso health district during the 2017 and 2018 campaigns. A panel including all CBDs was created. Their capacities were observed after: (1) initial training for the 2017 season; (2) refresher training for that year’s fourth round; and (3) initial training for the 2018 season. All were invited to complete a questionnaire at the end of training with 27 multiple-choice questions on their main tasks. Observers noted content coverage and conditions under which training sessions were conducted. Results The 612 CBDs showed, on average, high understanding of their tasks from the start of the annual campaigns. Tasks related to communicating with parents and reporting were best mastered. Their capacities grew from round to round and campaign to campaign, after most had undergone training and been supervised by head nurses. The greatest progress was in the technical components, considered more complex, which involved selecting eligible children, choosing the correct drug packet, and referring children to health professionals. Retaining CBDs from one round to the next benefited everyone, whatever their starting level. Groups that initially obtained the lowest scores (women, illiterates, youngest/oldest) progressed the most. Conclusion These results confirm the potential of using CBDs under routine programme implementation. Mandating CBDs with targeted tasks is a functional model, as they achieve mastery in this context where investments are made in training and supervision. Losing this specificity by extending CBDs’ mandates beyond SMC could have undesirable consequences. The added value of retaining committed CBDs is high. It is suggested that motivation and commitment be considered in recruitment, and that a supportive climate be created to foster retention.

The objectives of this study were to explore the extent to which adolescents adopted COVID-19 preventive measures in the first few months of the pandemic and to understand their adoption by looking at interconnected adoption-related factors and determining the strength of these factors, particularly among subgroups not expected to be early adopters.Analyses focus on data collected during Spring 2020 from 29 eastern Quebec secondary schools that participated in the COMPASS study. Participants (n = 6052) self-reported their knowledge, perception of risk and preventive practices to do with the COVID-19 pandemic. Data were analyzed using structural equation models based on gender and anxiety level.The majority of respondents reported adopting the recommended COVID-19 preventive measures. The results showed three paths leading to adolescents' adoption of these measures: pandemic knowledge; perception of risk related to COVID-19; and, in particular, discussions with relatives about preventive measures and what to do in case of infection.While most of the adolescent participants in this study appeared to comply with COVID-19 preventive measures, factors such as discussions with relatives emerge as elements to foster in order to improve adolescents' adoption of preventive measures.La présente étude avait pour objectifs d’explorer dans quelle mesure les adolescents ont adopté des mesures préventives contre la COVID-19 au cours des premiers mois de la pandémie et de comprendre leur adoption par l’examen de facteurs indépendants liés à l’adoption et par la détermination de la puissance de ces facteurs, en particulier parmi les sous-groupes qui ne sont pas censés être les premiers à adopter de telles mesures.Les analyses portent sur des données recueillies au printemps 2020 auprès de 29 écoles secondaires de l’est du Québec qui ont participé à l’étude COMPASS. Les participants (n = 6 052) ont déclaré eux-mêmes leurs connaissances, leur perception du risque et les pratiques de prévention à adopter dans le contexte de la pandémie de COVID-19. Les données ont été analysées à l’aide de modèles d’équation structurelle fondés sur le sexe et le niveau d’anxiété.La majorité des répondants ont déclaré avoir adopté les mesures préventives recommandées contre la COVID-19. Les résultats ont montré trois voies menant à l’adoption de ces mesures par les adolescents : les connaissances sur la pandémie, la perception du risque lié à la COVID-19 et, en particulier, les discussions avec les proches au sujet des mesures préventives et de ce qu’il faut faire en cas d’infection.Même si la plupart des participants adolescents à cette étude ont semblé se conformer aux mesures préventives contre la COVID-19, des facteurs comme les discussions avec les proches émergent en tant qu’éléments à favoriser pour améliorer l’adoption des mesures préventives par les adolescents.Adolescents’ compliance of COVID-19 preventive measures is high, even in subgroups with lower adoption rates. In addition to accurate pandemic knowledge and proper risk perception, discussions with relatives should also be considered as a means of improving adoption of COVID-19 preventive measures by adolescents.Le respect des mesures préventives contre la COVID-19 par les adolescents est élevé, même parmi les sous-groupes affichant des taux d’adoption plus faibles. Outre des connaissances précises en matière de pandémie et une bonne perception des risques, les discussions avec les proches sont un autre moyen à envisager pour améliorer l’adoption par les adolescents de mesures préventives contre la COVID 19.

Teenagers' vaccination has become crucial to limit the COVID-19 transmission in the population. To increase the vaccination rate of this age group, a school-based vaccination campaign was launched in Québec, Canada from June 7 to 18, 2021. This study aimed to analyze trajectories of vaccination coverage over time among students attending 37 high schools. The study explored whether school-based vaccination campaigns contributed to the progression of the vaccination coverage and attenuated disparities in vaccination coverage across schools. On average, first dose coverage quickly increased from 30.6% to 81.5% between June 6 and 18, 2021, after the launch of the campaign. As of August 13, 2021, first dose coverage had reached 87.9% and 64.9% for the second dose coverage. Public schools with poorer student populations had 6.5 points of percentage lower first dose vaccination rates (95%CI 0.3%; 12.6%) compared to other schools. A higher level of concern related to the pandemic among students was associated with a 4.3 points of percentage increased coverage (95%CI 0.7%; 8.0%). The initial uneven distribution in first dose coverage decreased dramatically by the end of the campaign. Similar trends were observed for the second dose, although between schools' inequality at the end of the period of observation was significantly larger. The school-based vaccination campaign might have initially contributed to a prompt rise in vaccination coverage and helped the disadvantaged schools to reach similar vaccination coverage as seen in other schools. In addition to being an efficient way to achieve rapidly high vaccination coverage, the school-based approach might contribute to increase equity in vaccination distribution.

Purpose The impact of the COVID-19 pandemic on adolescent mental health is a global concern; however, most research is cross-sectional or started after the pandemic response began and thus unable to evaluate within-individual change. The purpose of this prospective study was to evaluate the effect of the initial COVID-19 response on adolescent mental health and ill-health as a natural experiment. Methods We used 3-year linked data from the COMPASS study, including 7,653 Canadian (Quebec, Ontario) adolescents from which 2,099 completed surveys in all three waves (pre-COVID-19 [2018 and 2019] and online [May–July 2020], 2–3 months into the pandemic). A structural equation modeling approach to fixed effects and a difference-in-differences design were used to estimate pre-COVID-19–to–early lockdown change in mental health (psychosocial well-being [flourishing—reverse scored]) and ill-health (depression and anxiety symptoms), compared with 2018-to-2019 change. Models were adjusted for self-selection, age of entry into the cohort, and sociodemographics. Results Depression, anxiety, and reverse-flourishing scores increased across all waves; however, the mental health changes from the pre-COVID-19 wave (2019) to 2020 were not greater relative to the changes seen across the 2018-to-2019 waves. Conclusions Our results do not support a detrimental effect of the initial stages of the COVID-19 lockdown measures on adolescent mental health. The deterioration in mental health in the early COVID-19 response was less than the decline found over a prepandemic period. Further prospective research is needed to explore the impact of the prolonged pandemic and related measures on adolescents and inequitable effects in population subgroups.

Introduction Men can play crucial roles at each stage of HIV mother-to-child-transmission (MTCT) prevention. Low male involvement in preventative MTCT (PMTCT) in Burkina Faso is partially associated with increased MTCT rates in the country. Male involvement is at the intersection of individual experiences, social locations, organizational and systemic forces. It is crucial that PMTCT interventions are co-designed with all stakeholders, using approaches which account for such interconnected elements. This study, aims to provide a deeper understanding of male involvement using an intersectionality framework. Methods We used an intersectional theoretical approach as it positions male involvement at the intersection of social location, systemic forces, individual experiences, and dynamics within couples. We applied an interpretative qualitative description design. The study was performed at St-Camille’s hospital in Ouagadougou, Burkina Faso. Our sample was theoretical to contrast for individual experiences and socioeconomic characteristics. Eligible women were identified via chart review and invited to participate with their male partners. We conducted individual semi-structured interviews with 12 couples. We performed a semantic thematic analysis using QDA Miner to identify themes and patterns among subjective perspectives, while accounting for variations between individuals. Results We interviewed 12 couples; 6 were serodiscordant. All women were HIV-positive. Participant ages ranged from 23 to 48 years. We found male involvement to be multidimensional and multifaceted, covering a large spectrum (from rejection to true partnership) and diverse involvement. Male involvement was limited by competing priorities, contradictory expectations, organizational opportunities and societal beliefs. We found interactions with caregivers impacted male involvement. Conclusion This study contributed to enhancing our understanding of male involvement in PMTCT of HIV as a dynamic result of the interconnected individual, organizational and systemic experiences. Increasing male involvement will require implementation of coordinated interventions. Such interventions must strive to simultaneously integrate individual, organizational and systemic actions together.

BackgroundGiven the high rates of cannabis use among Canadian youth and that adolescence is a critical period for cannabis use trajectories, the purpose of this paper was to examine the effect of the early stages of the COVID-19 pandemic period on youth cannabis use in the context of a natural experiment.We used 3-year linked data from the COMPASS study, including 7653 Canadian (Quebec, Ontario) adolescents from which 1937 completed all 3 survey waves (pre-COVID-19 [2018, 2019] and online [2020] during the early pandemic period [May–July 2020]). Structural equation modeling (SEM) and double difference (DD) models were used to estimate pre-COVID-19 to initial COVID-19 pandemic period change (2019–2020) in cannabis use (monthly, weekly, daily) compared to 2018 to 2019 change to adjust for age-related effects. Models were adjusted for age of entry into the cohort and sociodemographic characteristics.ResultsIn the SEM and DD models, monthly, weekly, and daily cannabis use increased across all waves; however, the expected increases from the pre-COVID-19 wave (2019) to the initial COVID-19 period wave (2020) were lesser relative to the changes seen across the 2018 to 2019 waves. The cross-sectional data from May to July 2020 identified that the majority of youth who use cannabis did not report increased cannabis use due to COVID-19 or using cannabis to cope with COVID-19.ConclusionDuring the early stages of the COVID-19 pandemic period, there does not appear to be a detrimental effect on youth cannabis use, when adjusted for age-related changes. Further prospective research is needed to explore the impact of the ongoing pandemic response on youth cannabis use onset and progression.

Background Boys use cannabis at a younger age and more frequently than girls. It has been suggested these sex differences might vary according to students' relationship to school. We explored whether the association between sex and adolescents' cannabis use varies among schools and according to students' school connectedness. Methods The study population consisted of all students from 11 secondary schools in the greater Quebec City area. The sample included 6185 respondents in years 1 to 5 at the secondary level (equivalent to grades 7-11). Study outcomes were monthly cannabis use and early cannabis use. Results The association between sex and monthly cannabis use varied significantly among schools after controlling for students' main characteristics and school socioeconomic environment. We found a statistically significant modifying effect of school connectedness on the association between sex and monthly cannabis use. For early cannabis use, we found no modifying effect of school connectedness nor any association with sex. Conclusions Measures to reduce adolescents' cannabis use could be better adapted to local context and more tailored to specific higher-risk groups. School connectedness is a protective factor for cannabis use, although this effect appears stronger for girls than boys.

Summary Canada's history of nation building, combined with its status as a so-called middle power in international affairs, has been translated into an approach to global health that is focused on equity and global citizenship. Canada has often aspired to be a socially progressive force abroad, using alliance building and collective action to exert influence beyond that expected from a country with moderate financial and military resources. Conversely, when Canada has primarily used economic self-interest to define its global role, the country's perceived leadership in global health has diminished. Current Prime Minister Justin Trudeau's Liberal federal government has signalled a return to progressive values, driven by appreciation for diversity, equality, and Canada's responsibility to be a good global citizen. However, poor coordination of efforts, limited funding, and the unaddressed legacy of Canada's colonisation of Indigenous peoples weaken the potential for Canadians to make meaningful contributions to improvement of global health equity. Amid increased nationalism and uncertainty towards multilateral commitments by some major powers in the world, the Canadian federal government has a clear opportunity to convert its commitments to equity and global citizenship into stronger leadership on the global stage. Such leadership will require the translation of aspirational messages about health equity and inclusion into concrete action at home and internationally.

Objective To identify the factors associated with home births in the Kaya health district in Burkina Faso, where child delivery was free of charge between 2007 and 2011. Methods Both qualitative and quantitative data were collected from the Kaya Health and Demographic Surveillance System (Kaya HDSS) among women who delivered at home or in a health facility between January 2008 and December 2010. Multilevel logistic regression was applied to quantitative data, while the qualitative data were analyzed thematically based on emerging themes, subthemes, and patterns across group and individual cases. Results The findings indicate that 12% (n = 311) of childbirths occurred at home (n = 2560). Key factors associated with home birth were age, distance from the household to the primary health center, and prenatal visits. The qualitative analysis showed that immediate child delivery, previous experience of giving birth at home, negative experiences with health centers, fear of cesarean delivery, and lack of transport are key predictors of home births. Conclusion Though relevant, addressing the financial barrier to health care is not enough. Additional measures are necessary to further reduce the rate of home births.

Background Since 2014, the Burkina Faso government has made Seasonal Malaria Chemoprevention (SMC) a priority in its strategic plan to fight against malaria among children aged from 3 to 59 months. Very few studies have examined the care provided by community health workers in the framework of this strategy. The purpose of this study was to evaluate the level of quality of care provided by the latter. Methods This was a mixed study. The quantitative component consisted of a non-participant observation of community health workers during the administration of care. The qualitative component consisted of one-on-one interviews with community health workers, child caregivers and head nurses. Five dimensions (organizational accessibility, interpersonal relationship, technical competence, safety of care and satisfaction of child caregivers) adapted from the Donabedian quality of care model were used to assess the quality level of care. The Corlien et al. Health Systems Research Program Implementation Scale was used to establish quality scores for each of the five dimensions. The study sites were the health centers located in the administrative centers of the 4 communes of the health district of Boulsa. The data were collected during the first cycle of the 2017 SMC campaign. Results A total of 14 active pairs (28 CHWs) were observed and 40 in-depth interviews with community health workers, Head nurses in duty and community leaders were conducted. The results show that community health workers worked in pairs. They had all received SMC training and possessed equipment to do their job. The dimensions of organizational accessibility and satisfaction of the caregivers were rated as good. The dimensions of interpersonal relationship and technical competence were judged to be of an acceptable score. Safety of care was judged to be of a low-level score. The overall quality of care was considered acceptable. Conclusion The results of this study have shown that despite the difficulties faced by community health workers, they manage to deliver acceptable quality of care. Their use would be an asset for SMC in particular and for the health system in general. Electronic supplementary material The online version of this article (10.1186/s12913-019-4299-3) contains supplementary material, which is available to authorized users.

No abstract available.

To estimate the impact on maternal and child mortality after eliminating user fees for pregnant women and for children less than five years of age in Burkina Faso.Two health districts in the Sahel region eliminated user fees for facility deliveries and curative consultations for children in September 2008. To compare health-care coverage before and after this change, we used interrupted time series, propensity scores and three independent data sources. Coverage changes were assessed for four variables: women giving birth at a health facility, and children aged 1 to 59 months receiving oral rehydration salts for diarrhoea, antibiotics for pneumonia and artemesinin for malaria. We modelled the mortality impact of coverage changes in the Lives Saved Tool using several scenarios.Coverage increased for all variables, however, the increase was not statistically significant for antibiotics for pneumonia. For estimated mortality impact, the intervention saved approximately 593 (estimate range 168-1060) children's lives in both districts during the first year. This lowered the estimated under-five mortality rate from 235 deaths per 1000 live births in 2008 to 210 (estimate range 189-228) in 2009. If a similar intervention were to be introduced nationwide, 14,000 to 19,000 (estimate range 4000-28,000) children's lives could be saved annually. Maternal mortality showed a modest decrease in all scenarios.In this setting, eliminating user fees increased use of health services and may have contributed to reduced child mortality.Estimer l'impact sur la mortalité maternelle et la mortalité infantile après la suppression du ticket modérateur pour les femmes enceintes et les enfants âgés de moins de cinq ans au Burkina Faso.Deux districts sanitaires dans la région du Sahel ont supprimé le ticket modérateur pour les accouchements et les consultations curatives pour les enfants en septembre 2008. Afin de comparer la couverture en matière des soins de santé avant et après ce changement, nous avons utilisé des séries chronologiques interrompues, des scores de propensions et trois sources indépendantes de données. Les changements de couverture ont été évalués pour 4 variables: les femmes accouchant dans un établissement de santé et les enfants âgés de 1 à 59 mois recevant des sels de réhydratation par voie orale pour la diarrhée, des antibiotiques pour la pneumonie et de l'artémisinine pour le paludisme. Nous avons modélisé l'impact des changements de la couverture sur la mortalité dans « Lives Saved Tool » en utilisant plusieurs scénarios.La couverture a augmenté pour toutes les variables; cependant, l'augmentation n'était pas statistiquement significative pour les antibiotiques administrés pour traiter la pneumonie. En ce qui concerne l'impact estimé sur la mortalité, l'intervention a sauvé approximativement 593 vies d'enfants (fourchette d'estimation: 168–1060) dans les 2 districts pendant la première année. Cela a diminué le taux estimé de mortalité des enfants de moins de 5 ans, de 235 décès pour 1000 naissances vivantes en 2008 à 210 décès pour 1000 naissances vivantes (fourchette d'estimation: 189–228) en 2009. Si une action similaire était lancée à l'échelle nationale, cela pourrait sauver 14 000 à 19 000 vies d'enfants (fourchette d'estimation: 4000–28 000) annuellement. La mortalité maternelle n'a montré qu'une diminution modeste dans tous les scénarios.Dans cette région, la suppression du ticket modérateur a augmenté l'utilisation des services de santé et a peut-être contribué à la réduction de la mortalité infantile.Estimar el impacto en la mortalidad materna e infantil después de la eliminación de las cuotas de los usuarios para las mujeres embarazadas y para los niños menores de cinco años de edad en Burkina Faso.En septiembre de 2008, dos distritos de salud en la región del Sahel eliminaron las cuotas para los usuarios en las maternidades y las consultas curativas para niños. A fin de comparar la cobertura sanitaria antes y después de este cambio, se utilizaron series de tiempo interrumpido, puntuaciones de propensión y tres fuentes de datos independientes. Se evaluaron cuatro variables en los cambios en la cobertura: mujeres que dieron a luz en un centro de salud y niños de 1 a 59 meses que recibieron sales de rehidratación oral para la diarrea, antibióticos para la neumonía y artemisinina para la malaria. Expusimos el impacto en la mortalidad de los cambios de cobertura en la herramienta "Lives Saved Tool" empleando varios escenarios.La cobertura aumentó para todas las variables, sin embargo, el aumento no fue estadísticamente significativo en el caso de los antibióticos para la neumonía. Por impacto de la mortalidad estimado, la intervención salvó aproximadamente la vida de 593 niños (rango estimado 168 - 1060) en ambos distritos durante el primer año. Esto redujo la tasa estimada de mortalidad de menores de cinco años de 235 muertes por cada 1000 nacidos vivos en 2008 a 210 (rango estimado 189–228) en 2009. Una intervención similar puesta en práctica a nivel nacional podría salvar la vida a entre 14 000 y 19 000 niños al año (rango estimado 4000–28 000). La mortalidad materna mostró una disminución modesta en todos los escenarios.En esta configuración, la eliminación de las cuotas para los usuarios aumentó la utilización se los servicios sanitarios y pudo haber contribuido a reducir la mortalidad infantil.تقدير الأثر على معدل وفيات الأمهات والأطفال بعد إلغاء الرسوم المفروضة على المستخدمين بالنسبة للنساء الحوامل والأطفال الأقل من خمس سنوات في بوركينا فاسو.ألغت منطقتان صحيتان في إقليم الساحل الرسوم المفروضة على المستخدمين من أجل إيتاء المرافق والمشاورات العلاجية للأطفال في أيلول/سبتمبر 2008. ولمقارنة تغطية الرعاية الصحية قبل هذا التغير وبعده، استخدمنا السلاسل الزمنية المتقطعة ودرجات القابلية وثلاثة مصادر مستقلة للبيانات. وتم تقييم التغيرات في التغطية للتوصل إلى أربعة متغيرات: النساء اللاتي يلدن في مرفق صحي، والأطفال الذين تتراوح أعمارهم من شهر إلى 59 شهراً الذين يتلقون أملاح الإماهة الفموية لعلاج الإسهال، والمضادات الحيوية لعلاج الالتهاب الرئوي، والأرتيميسينين لعلاج الملاريا. وقمنا بنمذجة أثر التغيرات في التغطية على معدل الوفيات في أداة الأرواح التي تم إنقاذها باستخدام العديد من السيناريوهات.ازدادت التغطية بالنسبة لجميع المتغيرات، ولكن لم تكن الزيادة كبيرة من الناحية الإحصائية بالنسبة لمتغير المضادات الحيوية لعلاج الالتهاب الرئوي. وبالنسبة للأثر على معدل الوفيات المقدر، أدى التدخل إلى إنقاذ أرواح 593 طفلاً تقريباً (نطاق التقدير من 168 إلى 1060) في كلتا المنطقتين خلال السنة الأولى. وأدى هذا إلى خفض معدل الوفيات المقدر للأطفال دون سن الخامسة من 235 وفاة لكل 1000 وليد حي في 2008 إلى 210 وفاة (نطاق التقدير من 189 إلى 228) في 2009. وفي حالة تقديم تدخل مشابه على الصعيد الوطني، من الممكن إنقاذ أرواح من 14000 إلى 19000 طفل (نطاق التقدير من 4000 إلى 28000) سنوياً. وأظهر معدل وفيات الأمهات انخفاضاً متواضعاً في جميع السيناريوهات.أدى إلغاء الرسوم المفروضة على المستخدمين في هذه البيئة إلى زيادة استخدام الخدمات الصحية وربما أسهم في خفض معدل وفيات الأطفال.估计布基纳法索消除孕妇和未满五岁儿童用户费用后对孕产妇和儿童死亡率的影响。2008年9月萨赫勒地区两个卫生区取消了用户住院分娩和儿童治疗咨询费用。为比较此变更前后医疗覆盖情况，我们使用了中断时间序列、倾向分数和三个独立数据源。四个变量的覆盖率变化得到了评估：妇女在医疗机构分娩、1至59个月孩子获得腹泻口服补液盐、治疗肺炎的抗生素和治疗疟疾的青蒿素。我们在生命挽救工具中使用几个场景模仿覆盖变化对死亡率的影响。所有变量的覆盖都有增加，然而，肺炎抗生素在统计上没有显著增加。估计死亡率的影响方面，在两个地区，干预在第一年挽救约593（估计范围168-1060）名儿童的生命。5岁以下儿童死亡率从2008年每千例活产235人降低到2009年的210人（估计范围189-228）。如果全国采用类似的干预，每年可以挽救1.4-1.9万（估计范围0.4-2.8万）名儿童。所有场景孕产妇死亡率显示有适度降低。在此环境中，免除用户费用增加了卫生服务的使用，可能对降低儿童死亡率发挥了作用。Определить воздействие отмены платы за медицинские услуги, взимаемой с беременных женщин и детей младше пяти лет, на уровень материнской и детской смертности в Буркина-Фасо.Два административных округа в регионе Сахель в сентябре 2008 года отменили плату, взимаемую с пациентов за роды в медицинском стационаре и за медицинские консультации для детей. Результаты оценили по 4 показателям: роды в медицинском стационаре, получение детьми от 1 до 59 месяцев пероральной регидратационной соли при диарее, антибиотиков при пневмонии и артемизина при малярии. Мы смоделировали воздействие изменений на уровень смертности с помощью инструмента «Спасенные жизни», используя несколько сценариев.Результаты улучшились по всем четырем показателям, однако улучшение статистических данных по использованию антибиотиков при лечении пневмонии не было достаточно высоким. В отношении влияния на уровень смертности предпринятые меры помогли спасти жизни примерно 593 детей (оцениваемый диапазон 168–1060) в обоих округах в течение одного года. Это позволило понизить предполагаемый уровень смертности детей в возрасте младше 5 лет с 235 смертей на 1000 рожденных живыми в 2008 году до 210 (оцениваемый диапазон 189–228) в 2009 году. Если предпринять аналогичные меры по всей стране, это позволит сохранить от 14 000 до 19 000 детских жизней в год (оцениваемый диапазон 4000–28 000). Показатели материнской смертности понизились незначительно во всех рассматриваемых сценариях.В данной ситуации отмена платы, взимаемой с пациентов, позволила повысить уровень пользования медицинскими услугами и способствовала сокращению детской смертности.

Thirty years after Alma-Ata, there has been an upsurge of interest in community health workers (CHWs) in low- and middle-income countries. This echoes several strategic policies recently endorsed by the World Health Organization and its global call to re-establish the primary healthcare (PHC) policy. However, we are witnessing a reframing of this approach rather than its renewal. In particular, the way CHWs are conceptualized has changed considerably. Far from serving as promoters of social change and community empowerment, today we expect them to act as front-line clinicians. This medicalization of CHWs results from a systemic erosion of health promotion’s influence over the last 20 years. Community case management of malaria perfectly illustrates this shift towards a pragmatic, medically centered, use of CHWs. Taking this example, we will discuss the pitfalls of this task-shifting strategy put forward by international health actors, and make suggestions to reattribute a mission of health promotion to CH...

Background This study evaluated the effects on healthcare access inequities of an intervention exempting children under 5 years from user fees in Burkina Faso. Methods The design consisted of two complementary studies. The first was an interrupted time series (56 months before and 12 months after) study of daily curative consultations according to distance (

Resumen Este artículo repasa los enfoques a la vulnerabilidad en el campo de la salud pública y presenta 10 trabajos sobre cómo abordarla en África. Entendemos la vulnerabilidad a la vez como situación y como proceso. Las desigualdades sociales son evidentes y se exacerban en tres dimensiones clave de la vulnerabilidad: el nivel inicial de bienestar, el grado de exposición al riesgo y la capacidad de gestionar el riesgo de manera efectiva. Subrayamos las interacciones dinámicas en virtud de las cuales se genera una relación entre la privación material y social, la pobreza, la impotencia y la mala salud: los riesgos o percances (shocks) y sus repercusiones sobre la salud están íntimamente interrelacionados y se refuerzan mutuamente en un círculo que multiplica la vulnerabilidad a menos que se realicen intervenciones eficaces. Gracias a un proceso inductivo que no empieza con una definición o una medición a priori de la “vulnerabilidad” y que no presupone la existencia de “grupos vulnerables” fijos, pudimos por un lado reafirmar los aspectos centrales de los marcos conceptuales existentes y por otro considerar de forma diferente la literatura que aborda específicamente la vulnerabilidad y la resiliencia a nivel de la población así como otro tipo de literatura - por ejemplo, en materia de ecología y en torno al concepto de fragilidad en los estudios sobre envejecimiento - con la que posiblemente no estén familiarizados los investigadores sobre salud y pobreza en África. Invitamos a realizar una labor conceptual y empírica sobre la vulnerabilidad en marcos de sistemas complejos. Estas perspectivas subrayan los contextos y la causalidad no lineal, dando más peso por lo tanto a los análisis de vulnerabilidad y de resiliencia en tanto que marcadores de las interacciones dinámicas y como propiedades emergentes de estas interacciones. Aceptamos una definición operativa de vulnerabilidad y reconocemos que algunos grupos de personas susceptibles de ser definidos tienen más probabilidades que otros de sufrir perjuicio como consecuencia de su exposición a los riesgos para la salud. Pero sugerimos que de lo que se trata en realidad – tanto a nivel intelectual como político y en materia de elaboración de políticas- es de comprender la dinámica, los significados y las relaciones de poder que subyacen a las instancias y procesos reales de vulnerabilidad y perjuicio y darles respuesta.