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Introducing Onsite Antenatal Syphilis Screening in Burkina Faso

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Introducing Onsite Antenatal Syphilis Screening in Burkina Faso Bocoum et al. BMC Health Services Research (2017) 17:378 DOI 10.1186/s12913-017-2325-x RESEARCHARTICLE Open Access Introducing onsite antenatal syphilis screening in Burkina Faso: implementation and evaluation of a feasibility intervention tailored to a local context Fadima Yaya Bocoum1,2*, Grissoum Tarnagda1, Fabrice Bationo1, Justin R. Savadogo3, Sarata Nacro4, Séni Kouanda1,5 and Christina Zarowsky2,6 Abstract Background: Although the advantages of introducing point of care testing for syphilis in antenatal care (ANC) are well documented, there is little evidence on how to address structural issues within health systems. A better understanding of how these interventions work in a range of settings and contexts is needed in order to overcome bottlenecks at health system level. To better understand the relationships between implementation and context we developed and implemented an intervention focused on integrating a rapid screening test for syphilis in ANC services in rural primary health care facilities in Burkina Faso. This manuscript describes the intervention and reports on feasibility and acceptability of the intervention, the facilitators and barriers to the implementation of this intervention and the likelihood that point of care test for syphilis will become routinely incorporated in practice. Methods: In Kaya Health and Demographic Surveillance System (Kaya HDSS), all 7 primary healthcare facilities were selected for intervention in 2013. A participatory approach was used to design and implement an antenatal syphilis screening intervention. The Normalization Process Model (NPM) proposed by May et al. was adapted in order to identify barriers and facilitators and to explore the likelihood to become routinely incorporated in practice. Registers, Observations (n = 14 ANC 1) of interactions between patients and health workers during ANC and interviews with health workers (n = 14) were our data sources. Results: An intervention that included onsite training, provision of supplies and medicines, quality control and supervision was implemented in 7 health facilities in 2013. Rapid syphilis test and treatment were delivered during ANC within the examination room with no specific additional mechanism regarding staff organization. The perceived barriers were lack of training of all staff, workload, stock-outs of consumables and lack of motivation of staff. Key facilitators included political environment, ease of use of test and acceptability to pregnant women. Conclusions: Onsite testing for antenatal syphilis is a feasible and acceptable intervention in ANC at primary health facility in Burkina Faso. The point-of care test for syphilis is more likely to be acceptable by health workers as routine service and incorporated as a normal practice. Trial registration: The study was retrospectively registered on ClinicalTrials.gov under the Trial Registration Number NCT03156751. Keywords: Syphilis, Screening, Antenatal care, Feasibility, Point of care test, Burkina Faso * Correspondence: [email protected] 1Département biomédical et santé publique, Institut de Recherche en Science de la Santé (IRSS), 03 BP: 7192 Ouagadougou 03, Burkina Faso 2University of Western Cape, School of Public Health, Cape Town, South Africa Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bocoum et al. BMC Health Services Research (2017) 17:378 Page 2 of 10 Background well documented, there is little evidence on how to ad- Syphilis in pregnancy poses major health risks for the dress the structural issues within the health system [17]. A mother and the fetus [1] and also increases the risk of better understanding on how the interventions work in a HIV transmission [2]. The World Health Organization range of settings and contexts is needed in order to over- (WHO) estimates that two million pregnant women come bottlenecks at health system level. When imple- each year are infected with syphilis globally [3]. The risk menting any intervention, how – indeed whether – it of vertical transmission could be up to 80% in early works depends on elements of context such as socioeco- latent syphilis [3]. Approximately 1.2 million pregnant nomic background, health system structure and dynamics, women with syphilis transmit the infection to their new- and other factors [18]. It is with a view to better under- born every year [4]. Each year, maternal syphilis is respon- standing the relationships between implementation and sible for at least 50,000 spontaneous abortions or context that we developed and implemented an interven- stillbirths and 500,000 premature births of babies infected tion focused on the integration of a rapid test for syphilis with congenital syphilis or who have low birth weight [3]. screening in the ANC services in primary health care In Burkina Faso, prevalence in pregnant women was 1.9%, facilities in Burkina Faso. with notable regional variations [5]. In 2011 in Kaya a Revised UK Medical Research Council guidance on semi urban setting the prevalence was 4.3% whereas in evaluating complex interventions [19] recommends de- Ouagadougou the capital city it was 2.1% [5]. scribing the intervention and context and reporting on Maternal syphilis is detectable by serological screening all stages of the process including feasibility evaluations. and is entirely treatable with penicillin. Consequently, The objectives of this study were to document oper- screening and treatment for syphilis has been recom- ational implementation of a pilot integration of a rapid mended as a routine part of antenatal care in many test for syphilis screening into routine antenatal services countries [6, 7]. Unfortunately, antenatal syphilis screen- and analyze the experience in order to draw lessons for ing is often poorly implemented in many sub-Saharan scaling up maternal syphilis screening in Burkina Faso. African countries [8]. The influence of health systems This manuscript reports on the experience of implement- issues on prenatal syphilis screening has been docu- ing antenatal syphilis screening with a point of care test, mented in several countries, such as Bolivia, Kenya and the identification of barriers and facilitators to integrating South Africa [9]. Yaya Bocoum et al. have documented this intervention into routine ANC in rural Burkina Faso. constraints related to syphilis screening at primary Finally it reports on the likelihood that point of care test health care facilities (CSPS) in Burkina Faso [10]. for syphilis will become routinely incorporated in practice. Syphilis screening in primary health care facilities during antenatal care (ANC) in Burkina Faso is con- Study site – kaya HDSS ducted using a syndromic approach, but the majority of The intervention was nested in the Kaya Health and syphilis cases are asymptomatic. Testing is available at Demographic Surveillance System (Kaya HDSS), located the hospital laboratories and conducted with a venereal in the Kaya health district in the North Central region of diseases research laboratory (VDRL) test or with a Burkina Faso, 100 Km from Ouagadougou, the capital Treponema pallidum hemagglutination assay (TPHA) city. It covers seven urban areas and 18 villages of the which require qualified personnel, laboratory equipment, health district. By the end of 2011, 64 480 inhabitants and a source of electricity, which limits their utility for living in 10 587 households were being followed. The primary health care facilities. population is very young as 55.5% are under 20 years of Currently, there are several available specific, rapid age. The Mossi are the predominant ethnic group and syphilis tests that are simple to use and could be imple- Islam is the main religion (78.9%). The majority of the mented at primary health care settings [11]. These rapid population of the HDSS (53.3%) has not attended school. tests for syphilis screening are available in Burkina Faso, Subsistence farming and livestock breeding are the two and four of them have had their performance and oper- main occupations. Artisanal mining is also significant. ational characteristics assessed [12]. Unfortunately they Within Kaya HDSS, dirt roads and bush paths provide are not widely adopted for ANC services. means of access to the villages. These roads present a Interventions to improve the outcomes of antenatal challenge for users especially during the rainy season syphilis screening have been implemented in low and when there are floods [20]. middle income countries where most congenital syphilis cases occur [13]. These interventions showed advantages Health facilities of screening with rapid diagnostic tests and treatment of Within Kaya HDSS, there are seven public primary syphilis among pregnant women such as cost effective- health facilities that offer ANC, one faith-based health ness [14–16]. Although the advantages of introducing center and one regional hospital. The faith-based facility point of care testing for
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