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Abstract
Objective This study aimed to evaluate the trends of the availability and readiness of the healthcare system to provide cardiometabolic (cardiovascular diseases (CVD) and diabetes) services in Burkina Faso in multiple political and insecurity crises context.
Design We performed a secondary analysis of repeated nationwide cross-sectional studies in Burkina Faso.
Data source Four national health facility survey data (using WHO Service Availability and Readiness Assessment (SARA) tool) conducted between 2012 and 2018 were used.
Participants In 2012, 686 health facilities were surveyed, 766 in 2014, 677 in 2016 and 794 in 2018.
Primary and secondary outcome measures The main outcomes were the availability and readiness services indicators defined according to the SARA manual.
Results Between 2012 and 2018, the availability of CVD and diabetes services significantly increased (67.3% to 92.7% for CVD and 42.5% to 54.0% for diabetes). However, the mean readiness index of the healthcare system to manage CVD decreased from 26.8% to 24.1% (p for trend <0.001). This trend was observed mainly at the primary healthcare level (from 26.0% to 21.6%, p<0.001). For diabetes, the readiness index increased (from 35.4% to 41.1%, p for trend=0.07) during 2012–2018. However, during the crisis period (2014–2018), both CVD (27.9% to 24.1%, p<0.001) and diabetes (45.8% to 41.1%, p<0.001) service readiness decreased. At the subnational level, the readiness index for CVD significantly decreased in all regions but predominantly in the Sahel region, which is the main insecure region (from 32.2% to 22.6%, p<0.001).
Conclusion In this first monitoring study, we found a low level and decreased trend of readiness of the healthcare system for delivering cardiometabolic care, particularly during the crisis period and in conflicted regions. Policymakers should pay more attention to the impact of crises on the healthcare system to mitigate the rising burden of cardiometabolic diseases.
- PUBLIC HEALTH
- CARDIOLOGY
- DIABETES & ENDOCRINOLOGY
- Cardiac Epidemiology
Data availability statement
Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. The dataset of the SARA survey that was used in this research is available at the Ministry of Health upon request to the Health Statistics Office (Soumaïla Traoré: traoresoumaila83@gmail.com).
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study provides for the first time the trend of the healthcare system prepareness to provide cardiometabolic care in Burkina Faso.
The survey combined the interview and direct observation to make sure that each tracer is or is not available.
Despite the training received by field staff of each survey, there is a residual desirability bias.
The readiness index might be overestimated in the insecure areas since surveys did not include inaccessible health facilities.
Background
Cardiometabolic diseases (CMD), including cardiovascular diseases (CVD) and diabetes, are major health problems worldwide, particularly in low/middle-income countries (LMICs).1 In sub-Saharan Africa (SSA), it has been projected that these diseases will exceed communicable diseases as the most common cause of death by 2030.2 Among the factors that influenced this rise are social and political determinants of health.1 Indeed, in developed countries, launching non-communicable disease (NCD)-specific responses within the healthcare system has contributed considerably to a declining NCD trend. Meanwhile, CMD are still rising in LMICs, particularly in SSA.1 As shown by Kengne et al3 in 2013, CMD significantly affect country’s economic growth, competitiveness and productivity.3 Due to the similarity in the management of HIV and chronic conditions such as NCD, the success in HIV management revealed that there is a possibility to address NCD well in such a context,4 5 if the healthcare system is well organised despite the low-resource setting.4 However, a recent review in 2020 showed that no country in Africa had met all the recommended indicators to integrate NCD services into primary healthcare: less than one-third had established national guidelines for NCD management, and only 13% had reported the availability of all essential NCD medicines and health facilities.6 Moreover, the geopolitical crises, including political and insecurity crises, which many countries of West Africa are facing, might have a negative impact on health system resilience and adaptability in this region.7 The early diagnosis and treatment of cardiovascular risk factors and diabetes are of vital importance for improving health outcomes and potentially limiting long-term organ damage.8
In Burkina Faso, CMD is an increasing public health issue that makes the country face a double burden of diseases. Indeed, recent estimates of the Global Burden of Diseases showed that CMD and its risk factors are increasing in Burkina Faso. Mortality due to ischaemic heart disease and stroke has increased by 32.3% and 34.1%, respectively, between 2009 and 2019 in the country.9 Mortality and disability due to CMD risk factors such as hypertension, high fasting plasma glucose and overweight have also increased by 43.6%, 53.9% and 80.8%, respectively.10 Since 2013, the government of Burkina Faso has been spending many efforts to strengthen the healthcare capacity to manage NCD, including CMD. These efforts include the implementation of therapeutic guidelines and protocols, the integration of a minimum healthcare package for NCD (WHO Packages for Essential NCD intervention (PEN),11 including CVD risk assessment and management, hypertension and diabetes management, for example) at the primary care level, the support of therapeutic education sessions for the self-management of NCD in health facilities and increasing the number of trained NCD management specialists.12 However, the country has been facing several unprecedented crises (politics and security) these recent years. Indeed, in October 2014, the country experienced a popular insurrection, followed in September 2015 by an attempted ‘coup d’état’ and terrorist attack (in many health regions) since 15 January 2016.7 In addition to human injuries, previous studies have highlighted that these crises might have a negative impact on maternal healthcare access, resiliency and adaptability of the health system.7 13 In contrast, cardiometabolic healthcare is long-term and continued healthcare to prevent complications and mortality. In this context, it is important to understand further ways to strengthen the healthcare system to manage CMD in the country. It is also urgent to investigate how the healthcare system’s capacity may be improved to address the increasing burden of CMD in this country. This study aimed to provide comprehensive data on the trend of CMD diagnosis and management capacity of the healthcare system in Burkina Faso and identify which domains of the healthcare system need to be targeted and strengthened. The findings of this study might inform ongoing policy efforts to improve CVD and diabetes services in Burkina Faso.
Methods
Study type and setting
We conducted a secondary analysis of the national health Service Availability and Readiness Assessment (SARA) surveys. It is a repeated survey that has been conducted every 2 years in Burkina Faso since 2012. Burkina Faso is located in the SSA region of West Africa, with a surface area of 272 960 km2. According to the latest population and housing census conducted in 2019, there are 20 487 979 inhabitants in Burkina Faso.14 Life expectancy at birth is 61.8 years. The proportion of the population living in urban areas has increased (according to the latest national population census) from 12.7% in 198515 to 26.3% in 2019.16 Healthcare is provided by 3121 functional healthcare facilities (including 12 dental offices) grouped in 70 health districts and 13 health regions. Many health regions (particularly the regions at the border with Mali and Niger i.e. Sahel, Nord, Est and Boucle du Mouhoun regions) are facing terrorist attacks (figure 1), which affect the availability and access to healthcare. The healthcare system is organised into three levels (primary, secondary and tertiary).
Map of locations of armed attacks between 2012 and 2018 (data extracted from https://acleddata.com/#/dashboard).
Data sources and description
In this study, we used the data from the SARA surveys. It is a comprehensive and widely applied health facility-based cross-sectional survey well described by the WHO.17 The SARA aimed to fill an important gap in monitoring health system performance.18 The survey included both public and private healthcare facilities across all levels of the healthcare system in the country. A stratified sampling strategy was used. All healthcare facilities at secondary and tertiary levels (national or regional hospitals plus polyclinics) were grouped in stratum 1. All healthcare facilities at primary level and scale 2 (district hospital and private clinic) were grouped in stratum 2 . Stratum 3 included all facilities of primary level and scale 1 (representing the peripheral healthcare facilities). For strata 1 and 2, all healthcare facilities were included in the survey. For stratum 3, a simple random sampling was applied to select peripheral health facilities. The indicators were considered representative at the national and regional levels.
For data collection, the WHO SARA standard questionnaire was used. A face-to-face interview with the heads of health facilities or any other authorised person was conducted. The direct observation method was also used to verify the availability of drugs and other health products and the functionality of medical equipment. The data collectors were sworn health workers. Health workers with high level of education and good experience in the healthcare practice were identified as team leaders. Field staff received extensive training in collection tools prior to starting each survey. Team leaders supported data collectors in data collection in the health facility of strata 1 and 2.
Outcome variable definition
The operational capacity of the healthcare facilities to provide cardiometabolic care was divided into two components: service availability and service readiness. The operational capacity of the healthcare facilities to provide diagnostic and/or treatment services for CVD and diabetes was assessed based on 12 tracers and 13 tracers, respectively. Table 1 describes each tracer. Each tracer was defined by a binary variable that was coded 1 if the tracer was available in the healthcare facility and 0 if not.
Tracer for cardiometabolic disease service availability and readiness
Independent variables were the level of healthcare (primary, secondary and tertiary), health facility type (public/private), residence (urban/rural) and health regions.
Statistical analysis
All analyses were performed according to the SARA manual of the WHO. We first summarised the availability of diabetes-specific and CVD-specific services as the percentage of the healthcare facilities offering diabetes and/or CVD diagnosis and/or management. We also evaluated the availability of each necessary tracer of the services. Second, we assessed the readiness as a score calculated for each domain (as a mean percentage of availability of the tracer within the domain). The domain score was calculated as follows: if n is the number of items available in a healthcare facility and N is the total number of items for that domain, then the domain score was equal to n/N×100. For a domain with five items (like medicines and products for CVD), the domain score was equal to n/5×100. Lastly, we calculated the diabetes and CVD service readiness index as the mean of all domain scores and presented it by the healthcare facilities’ characteristics and location (health region). If we consider a, b, c and d as the domain scores for the ‘staff and guidelines’, ‘equipment’, ‘diagnostic capacity’, and ‘medicines and products’ domains, respectively, then the readiness index was equal to the sum of the scores of a, b, c and d divided by the number of domains ([a+b+c+d]/4).17 The readiness expresses the percentage of necessary items available for providing diabetes and CVD services at the healthcare facility. A shortage of these items denotes the inability of the healthcare facility to provide satisfactory services. The crude trend of availability of diabetes and CVD-specific services was assessed by the Χ2 test for trend using package ptrend in Stata.19 We measured the adjuted trend of the readiness index using multivariable linear regression analysis with the health facilities’ characteristics as covariates. The multicollinearity between the healthcare facilities’ characteristics was checked after each regression analysis. We make a focus on the geopolitical period (2014–2018). The overall readiness of each survey was mapped using equal interval classification method to divide the readiness index into seven classes to accurately show the variation over time and between regions. We also plotted the readiness trend and its confident intervals (CI) for each region. The analysis accounted for the healthcare facilities’ weightage since the probability of selection was different depending on the level of the facility in the healthcare system. All analyses were done using Stata V.17.0 and QGIS.
Patient and public involvement
Patients or the public were not involved in our research’s design, conduct, reporting or dissemination plans.
Results
Characteristics of the healthcare facilities surveyed
As shown in table 2, the number of healthcare facilities surveyed was 686 in 2012, 766 in 2014, 677 in 2016 and 794 in 2018. The response rate was 100% (686 of 686) in 2012, 98.2% (766 of 780) in 2014, 98.8% (677 of 685) in 2016 and 98.9% (794 of 803) in 2018. The majority of them provided primary healthcare. Furthermore, they were public facilities located in rural areas.
Characteristics of the healthcare facilities
Availability of each tracer for CMD
The percentage of healthcare facilities providing CVD services was 67.3% in 2012 and had significantly increased to 92.7% in 2018 (p for trend <0.001). This increasing trend of availability of CVD services was observed at all levels of the healthcare system. Indeed, this percentage had increased from 66.2% in 2012 to 92.0% in 2018 at the primary healthcare level and 82.6% (2012) to 94.8% (2018) at the secondary healthcare level. A similar trend was observed in private and public healthcare facilities and those located in urban and rural areas. Regarding the availability of diabetes-specific healthcare services, we found that the percentage of healthcare facilities offering this service had increased during the study period from 42.5% in 2012 to 54.0% in 2018 (p<0.001). Primary healthcare facilities mainly supported this trend. The increasing trend was observed in both public and private healthcare facilities in both residence locations (urban and rural) (see table 3).
Percentage of diabetes and cardiovascular disease service availability
Readiness index of healthcare facilities to manage CVD and diabetes
The average readiness index and mean domain score of each tracer are shown in table 4. The results of the analysis showed that the preparedness of the healthcare system to manage CVD decreased between 2012 and 2018 from 26.8% to 24.1% (p for trend <0.001). The decreased trend was most pronounced between 2014 and 2018 (27.9% to 24.1%, p<0.001). Regarding the mean domain score, staff and training demonstrated the highest negative trend during the study period since the mean domain score decreased from 18.2% to 10.1% (p<0.001). The domain of ‘medicines and products’ had the lowest mean domain score and also decreased from 13.3% in 2012 to 10.3% in 2018 (p<0.001) (table 4).
Domain score and readiness index for CVD and diabetes services
The overall readiness index of healthcare facilities to manage diabetes increased from 35.4% to 41.1% between 2012 and 2018 (p<0.001). However, when we looked at the trend between 2014 and 2018, we found that the readiness for diabetes decreased during this period (45.8% to 41.1%, p<0.001). Furthermore, when we looked at the trend of the domain score, we found out that the domain did not exhibit a similar trend. Indeed, during the study period, the equipment, diagnostic capacity and medicine domains significantly increased from 86.0% to 90.8% (p<0.001), 29.0% to 41.9% (p<0.001) and 17.7% to 23.4% (p<0.001), respectively, while the staff and training domain significantly decreased from 9.0% to 8.3% (p<0.001) (table 4).
Readiness index according to the healthcare facilities’ characteristics and health regions
Table 5 presents the readiness index according to the healthcare facilities’ characteristics. The readiness index for cardiovascular care decreased mainly in the primary and secondary-level healthcare facilities. It demonstrated a decrease in both public and private healthcare facilities. During the same period, the readiness index for diabetes care increased mainly in the primary-level healthcare facilities, including both public and rural healthcare facilities.
Readiness index of diabetes and cardiovascular disease services by the healthcare facilities’ characteristics
Regarding subnational variability of the readiness index (figure 2), we found out that the readiness of the healthcare facilities to manage CVD had significantly decreased in all regions but mainly in the Sahel region (β=−3.94; 95% CI: −5.15 to −2.72). However, the readiness index for the management of diabetes had increased in 4 out of the 13 health regions. They were Centre-Nord (β=1.90; 95% CI: 0.50 to 3.31), Centre-Est (β=2.04; 95% CI: 0.73 to 3.35), Boucle du Mouhoun (β=3.02; 95% CI: 1.56 to 4.49) and Nord (β=3.85; 95% CI: 1.83 to 5.89). During the same period, the readiness index for diabetes significantly decreased in the Centre-Sud region (β=−2.39; 95% CI: −3.51 to −1.26).
Readiness index of healthcare facilities to manage cardiovascular diseases (CVD) and diabetes by health regions. Trend was adjusted for type of health facilities, level of the health system and place of residence. Equal interval classification method was used to set legend of map.
Discussion
Key findings
This study is the first trend analysis of the healthcare system’s preparedness to manage CVD and diabetes in Burkina Faso. Our study showed that the availability of both CVD and diabetes services significantly increased between 2012 and 2018, mainly at the primary healthcare level. However, the preparedness of the healthcare system to manage CVD decreased during the same period. This negative trend was most significant for staff/training and medicines/products. For diabetes, this study highlighted that the preparedness of the healthcare system has, on average, increased between 2012 and 2018, particularly for some domains such as equipment, diagnosis, and medicines and products. However, the readiness for diabetes has decreased during the geopolitical crises period (2014–2018). When we looked at the trend of preparedness by the health facilities’ characteristics, we found that the readiness to manage CVD had decreased at all levels of the healthcare system in both rural and urban areas and all health regions. However, for diabetes, our study demonstrated an increasing readiness trend in primary healthcare facilities, public and rural health facilities, and four health regions. The negative trend, particularly for CVD, is most pronounced in Sahel region, which is the main insecure region of the country.
Availability and readiness of cardiometabolic healthcare services
As in our study, we learn from many previous studies that the availability and readiness of healthcare facilities to provide cardiometabolic-related health services remain suboptimal in many low-income countries despite the increasing efforts to prevent and control these diseases.20–23 Allen et al24 showed that in 2020, the mean implementation rate had increased from 39.0% in 2015 to 45.9% in 2017 and reached 47.0% in 2020. However, only one-third of the NCD policies have been implemented, and low-income countries had the lowest policy implementation rates.24 The 2019 global survey on the country capacity to manage NCDs highlighted that despite the substantial progress made in the last decade in NCD policy implementation, including the strengthening of healthcare systems and efforts to improve the availability of essential diagnosis services, NCD medicines and technologies remain critical, particularly in SSA.25 A systematic review conducted in SSA26 revealed that the CMD services were largely unavailable and unaffordable, and their capacity to manage CMD remains in the ‘infancy’ stage. The situation is more worrisome in Burkina Faso, as shown in our study, due to the geopolitical crises, which have negatively affected the adaptability of the healthcare system.7 Indeed, CVD and diabetes services have received little attention probably due to political instability since 2014 and terrorist attacks, which have kept the particular attention of the government these recent years. Most of the indicators have decreased during the geopolitical crises period. Indeed, geopolitical crises can weaken national infrastructures vital to health and health system governance, altering healthcare coverage and disturbing basic drug and equipment availability.27 The increasing readiness of diabetes services in the country between 2012 and 2014 might be due to the efforts of many non-governmental organisations like ‘Santé diabète’, which have implemented a country-level diabetes programme.28 This programme aimed to improve the quality of life of people living with diabetes in Burkina Faso by advocating for prevention and improving access to care. Many healthcare professionals were trained, and the system of diabetes medication supply was also improved in many health districts of the country.28
The critical gap in the capacity of the healthcare system in LMICs to manage CVD and diabetes is related to essential medicines, basic equipment and diagnostic investigations.29 30 At the same time, the WHO’s global voluntary target was to reach by 2025 an 80% availability of the affordable basic technologies and essential medicines required to treat the major NCD in both public and private facilities.31 As highlighted in our study, the availability of essential medicines to treat CVD and diabetes is a major challenge in the healthcare system in Burkina Faso. Many other studies in low-income countries have shown the suboptimal availability of NCD medicines20 32–36 due to the health cost and unaffordable price of these medicines.33 Furthermore, these medicines need to be appropriately used for the secondary prevention of NCD in LMICs.37 Indeed, a recent study also showed that statins are used by about 1 in 10 eligible people for the primary prevention of CVD and by 1 in 5 eligible people for secondary prevention.38 To reduce the premature deaths from NCDs by 25% by 2025, as highlighted in the Global NCD plan, at least 50% of the eligible people must receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes.31 The situation of availability of essential CVD medicine in Burkina Faso might be due to contextual constraints and powerful concurrent policies, which make it difficult for a holistic change in essential medicine availability.39 The availability of guidelines was among the lowest tracer in this study. Peck et al5 reported in 2014 that in many facilities in Tanzania, guidelines, diagnostic equipment and first-line drug therapy for the primary care of NCD were inadequate, and the management, training and reporting systems were weak. Krishnan et al40 claimed that the health facilities in India were not adequately prepared to address the burden of NCD since significant gaps were related to the availability of essential medicines, technologies, training of the available human resources, as well as counselling services for NCD. The results of several other studies using the WHO-SARA methodology in Bangladesh,21 41 Haiti,42 Uganda,43 44 Nepal,22 33 Kenya34 and Tanzania5 35 were in concordance with these findings. An analysis of the progress in integrating NCD services with primary healthcare in Africa revealed that only one-third (30%) of the countries have NCD guidelines.6 This lower integration of NCD service is due to critical capacity gaps in primary healthcare facilities, particularly workforce capacity, health system infrastructure and health information systems.45 Primary healthcare services are more likely to be used by the poorest population, since primary healthcare facilities are the most accessible source of healthcare.46 Therefore, improving primary healthcare may help address the inequality in cardiometabolic healthcare accessibility.46 In Burkina Faso, the first primary healthcare is mainly provided by non-physician health professionals. In our study period, no national guideline for CMD care was available. However, since July 2020, the Ministry of Health has adopted the WHO PEN and proposed a guideline for the main NCD including diabetes and CVD. This guideline aims to improve the integration of NCD healthcare in the current primary healthcare. Its implementation is ongoing in three pilot health districts.
The preparedness of the healthcare system is variable across the SSA region, as highlighted by Tesema et al6 in 2020. Other studies have also shown a subnational variation in the preparedness of healthcare facilities, as demonstrated in our study.21 22 Our study also showed a variability of readiness across the health regions, and the trend was also diverged by the health regions. Our findings demonstrated that the Sahel region was the most affected by the decline in the readiness of CVD services. Since 2015, this region has been facing terrorist attacks, which may have negatively affected access to and availability of healthcare services. Previous studies have shown that terrorist attacks constitute a new barrier to access healthcare in Burkina Faso.13 The negative trend of the readiness index in the Centre-Sud region might be explained by the fact that this region has not yet had a reference hospital (level 2 of the healthcare system) and it is not so far from the capital city. Many patients with NCD are referred to the national hospital located in the capital city. The negative trends of readiness for CVD and diabetes were also reported in regions with no reported cases of terrorist attacks in the study period. This finding suggests that many other causes of this negative trend need to be identified in a further study focused on health system evaluation.
Health policy implications of the findings
In this study, we found that the preparedness of the healthcare system to deal with CMD is suboptimal, with a decreasing trend for CVD in Burkina Faso. These findings have major health policy implications to adequately address the rising burden of these diseases in the country. Consistent with the review by Tesema et al6 in 2020, we strongly suggested (1) a reorientation of primary healthcare to better integrate the NCD services, (2) increasing the availability of trained primary healthcare workers and access to simplified guidelines, and (3) increased availability and access to essential medicines and technologies to prevent CMD. In addition to these suggestions, there is a need to adequately monitor the progress in the preparedness of the healthcare system to manage NCD particularly in primary healthcare facilities.46 Policymakers also need to address the geographical inequity in the preparedness of the healthcare system to address CMD despite the difficult context of multiple ongoing crises.
Strengths and limitations
We analysed the trend of the healthcare system’s preparedness to manage cardiovascular and diabetes-specific healthcare using a national sample of health facilities in Burkina Faso. The main limitation of this study is that the question about the availability of blood sugar testing was changed in 2014, 2016 and 2018 compared with 2012. However, we think that this change may not significantly affect the trend of this indicator. For each study year, the sample was representative of all 13 health regions of the country, which offered an opportunity to investigate for the first time the subnational disparities in the availability of cardiometabolic healthcare. We agree that this analysis focused on the healthcare facilities’ preparedness and did not include an assessment of the quality of clinical care received by the patients. Consequently, the findings of this study might not be extrapolated to the quality of cardiometabolic care. A recent study has shown that the indicators of the healthcare facilities’ preparedness to manage CMD are poor proxies for the quality of clinical care received by the patients.47 Furthermore, assessing the quality of clinical care using the preparedness of the healthcare system to manage CMD as a proxy is beyond the scope of the current study. Nevertheless, we think that this study provides useful information on the healthcare system, which might help policymakers to improve the prevention, diagnosis and quality of cardiometabolic48 care in Burkina Faso.
Conclusion
This study shows the suboptimal preparedness of the healthcare system to manage CVD and diabetes in Burkina Faso. Furthermore, it shows that the preparedness is decreasing over time particularly during the geopolitical crisis period despite the initiation of the NCD programme in 2013 in the country. The negative trend of preparedness of the healthcare system to manage CVD was mainly related to the staff, training, and medicine regardless of the health region and facility characteristics or the place of residence. We strongly suggest that health policymakers should pay more attention to NCD services in primary healthcare to strengthen the health workers’ capacity to manage CMD at all levels of the healthcare system despite the unprecedented crises that the country is facing. It is also necessary for policymakers to increase the availability and access to essential medicines and technologies to prevent CMD by strengthening the CMD medicines supply system and controlling the drug price.
Data availability statement
Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. The dataset of the SARA survey that was used in this research is available at the Ministry of Health upon request to the Health Statistics Office (Soumaïla Traoré: traoresoumaila83@gmail.com).
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and the protocol of this study was approved by the Ministry of Health’s Ethics Committee for Health Research, and informed consent was required for each participant before their inclusion in the study (deliberation no. 2020-10-231 of 07 October 2020). The confidentiality of the information collected has been mentioned in the informed consent form.
Acknowledgments
The authors acknowledge the Ministry of Health of Burkina Faso for providing the data.
References
Footnotes
Contributors FK-S, SK and SS conceptualised, and formulated research goals, objectives of the study and the lead methodology. KC analysed data with inputs from ST. KC wrote the first draft of the manuscript with inputs from SS, SK and FK-S. JK, JCY, PZ, PS and AZ critically reviewed the manuscript. FK-S and SK contributed to the acquisition of project financial support. All authors read, edited and approved the manuscript. KC assumes the role of the content guarantor.
Funding This work was supported by the Academie de Recherche et d’Enseignement Supérieur (ARES) of Belgium in the context of a research programme for development focused on cardiovascular diseases in Burkina Faso: CARDIO-PREV. SS received a postdoctoral fellowship from the Fonds de recherche du Québec Santé (FRQS).
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Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.