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The coverage of immunization against avoidable disease in the Republic of Benin as in other West African countries, is declining nowadays. To sustain the government effort, National Immunization Technical Advisory Groups (NITAG) were created technically and funded by the West African health organization (WAHO) and Preventive Medicine Agency in countries of the Economic Community of West African States (ECOWAS) including the Republic of Benin. The variation in experts’ methods of analyzing evidence sometimes results in risk error and lack of statistical power. This situation does not allow for the comparison of the scientific validity of certain recommendations made to policy makers, due to the lack of a rigorous framework. The aim of this paper is to design an improved framework to be used in the Republic of Benin in order to encourage a more harmonized approach based on evidence used by expert consultative committees. This framework shows four fundamental scientific steps including a Ministerial referral procedure, recommendation framework, evidence-based data collection, model analyses appropriate for expert advice on vaccines and child immunization, as well as three administrative steps including scientific discussion and work meetings without forgetting ethical aspects.

Hepatitis B virus (HBV) infection remains one of the major neglected health issues worldwide. In sub-Saharan Africa (SSA), HBV endemicity is high, with more than 8% of the population being chronic HBV carriers. Recently, WHO recommended that all infants should receive their first dose of the HBV vaccine as soon as possible after birth. Unfortunately, the incorporation of a birth dose of HBV in the expanded programme immunization (EPI) has not occurred in the majority of countries in SSA. From April to September 2017, a cross-sectional survey was conducted in two vaccine units located in southern Benin. We assessed the sustained anti-HBs antibody response in infants induced by a standard scheme of 3 doses of HBV vaccination (6, 10, 14 weeks) in comparison to a scheme of 4 doses with a birth dose included (0, 6, 10, 14 weeks). Blood samples were systematically collected in the first 140 children aged 9 months and their mothers who had consented to participate for the detection of HBs antigen and the quantification of anti-HBs antibodies. The prevalence of HBV infection among infants and mothers was 2.2% and 7.1%, respectively. Infants who received 4 doses of HBV vaccine had a significantly higher level of anti-HBs antibody than those who received 3 doses of vaccine (557.9 UI/L vs. 386.9 UI/L, respectively, P = 0.03). We also showed that the scheme of 4 doses was associated with a significantly higher sustained protective response in comparison to the scheme of 3 doses (aOR 2.49, 95% CI 1.03-6.03, P = 0.04). This result provides further evidence of the importance of administering HBV vaccine at birth, but also highlights the importance for the prevention of vertical transmissions. Additional studies are needed to better establish the cost-effectiveness of such a 4 doses immunization strategy before implementing the HBV vaccination at birth in the EPI., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The literature on migration-fertility relationship uses various measures of fertility, such as fertility rates, actual fertility and family size preferences. This study introduces a different measure-interbirth intervals over women's reproductive years-to examine how internal migration is associated with short interbirth intervals (less than 24 months) and long interbirth intervals (greater than 60 months) in Cotonou, the largest city of Benin Republic., Methods: The paper uses primary data on 2852 live births to 1659 women aged 15-49 years from the 2018 Fertility and Migration Survey in Cotonou. Competing-risks models were fitted for the analysis., Results: Nineteen percent of live births were of short interbirth intervals and 16% were of long interbirth intervals. The prevalence of short interbirth intervals was higher among migrants who spent less than 5 years in Cotonou (29%) than among non-migrants (19%) and earlier migrants (18%). Non-migrants had the highest proportion of long interbirth intervals (19%). Within the first 5 years following the migration to Cotonou, migrants had higher subhazard ratio (SHR) of short interbirth intervals (SHR: 1.71, 95% CI: 1.33-2.21) and lower SHR of long interbirth intervals (SHR: 0.64, 95% CI: 0.47-0.87) than non-migrants. This association holds after controlling for socioeconomic characteristics-but with a slightly reduced gap between migrants who spent less than 5 years in Cotonou and non-migrants. Afterwards and irrespective of women's socioeconomic backgrounds, migrants who spent 5 or more years in Cotonou and non-migrants had similar risks of short and long interbirth intervals. Finally, from 5 years of stay in Cotonou, migrants for reasons other than school or job were less likely to experience short interbirth intervals (SHR: 0.65, 95% CI: 0.46-0.98 for migrants who spent 5-10 years in Cotonou, and SHR: 0.74, 95% CI: 0.54-1.02 for migrants who spent more than 10 years in Cotonou) than non-migrants., Conclusion: Family planning programmes should mainly target migrants in the early years after their arrival in Cotonou. Moreover, non-migrants need to be sensitised on the adverse health outcomes of long interbirth intervals.

Background: We investigated whether adding community scheduled malaria screening and treatment (CSST) with artemether-lumefantrine by community health workers (CHWs) to standard intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) would improve maternal and infant health., Methods: In this 2-arm cluster-randomized, controlled trial, villages in Burkina Faso, The Gambia, and Benin were randomized to receive CSST plus IPTp-SP or IPTp-SP alone. CHWs in the intervention arm performed monthly CSST during pregnancy. At each contact, filter paper and blood slides were collected, and at delivery, a placental biopsy was collected. Primary and secondary endpoints were the prevalence of placental malaria, maternal anemia, maternal peripheral infection, low birth weight, antenatal clinic (ANC) attendance, and IPTp-SP coverage., Results: Malaria infection was detected at least once for 3.8% women in The Gambia, 16.9% in Benin, and 31.6% in Burkina Faso. There was no difference between study arms in terms of placenta malaria after adjusting for birth season, parity, and IPTp-SP doses (adjusted odds ratio, 1.06 [95% confidence interval, .78-1.44]; P = .72). No difference between the study arms was found for peripheral maternal infection, anemia, and adverse pregnancy outcomes. ANC attendance was significantly higher in the intervention arm in Burkina Faso but not in The Gambia and Benin. Increasing number of IPTp-SP doses was associated with a significantly lower risk of placenta malaria, anemia at delivery, and low birth weight., Conclusions: Adding CSST to existing IPTp-SP strategies did not reduce malaria in pregnancy. Increasing the number of IPTp-SP doses given during pregnancy is a priority., Clinical Trials Registration: NCT01941264; ISRCTN37259296.

Background: This study aims to provide baseline data on the resistance status to insecticides, the frequency of mechanisms involved and the impact of the association with the synergist piperonyl butoxide (PBO) on resistant Anopheles gambiae (s.l.) populations in two regions of northern Benin, prior to an indoor residual spraying campaign and introduction of next generation long-lasting insecticidal nets (LLINs) incorporating PBO., Methods: Adult Anopheles gambiae (s.l.) originating from larvae collected in two study regions (Alibori within the Kandi-Gogounou-Segbana districts and Donga within the Djougou-Copargo-Ouake districts) were tested with impregnated papers (bendiocarb 0.1%, pirimiphos-methyl 0.25%, permethrin 0.75% and deltamethrin 0.05%). The synergist PBO was used to check for the involvement of detoxification enzymes in pyrethroid resistant populations. Molecular analyses were performed for the identification of species within the Anopheles gambiae (s.l.) complex and kdr L1014F and G119S Ace-1 mutations. Biochemical assays assessed the activity of detoxification enzymes., Results: Anopheles gambiae (s.l.) was resistant to pyrethroids, with a mortality range of 25-83% with deltamethrin and 6-55% with permethrin. A significant increase in mortality was observed after pre-exposure to PBO for both deltamethrin (63-99%) and permethrin (56-99%). With bendiocarb, An. gambiae (s.l.) were susceptible in Kandi (99% mortality), with possible resistance (92-95%) recorded in Djougou, Copargo, Gogounou, Ouake and Segbana. All study populations were fully susceptible to pirimiphos-methyl. The frequencies of resistant mutations varied according to species and sites: 0.67-0.88 for L1014F kdr and 0-0.06 for G119S Ace-1. Three study locations (Djougou, Gogounou and Kandi) showed high oxidase activity and four sites (Djougou, Ouake, Copargo and Kandi) showed elevated esterase activity., Conclusions: This study confirms resistance to pyrethroids and suggests emerging bendiocarb resistance in An. gambiae (s.l.) populations in northern Benin. However, recovery of susceptibility to pyrethroids after PBO exposure, and susceptibility to organophosphates in the An. gambiae (s.l.) populations indicate that next generation LLINs incorporating PBO synergist combined with an indoor residual spraying (IRS) campaign with organophosphate insecticides may be regarded as alternative control tools.

Background: A multi-country, community-based trial on scheduled screening and treatment for malaria in pregnancy was conducted in Benin, The Gambia and Burkina Faso. Despite standardized procedures and outcomes, the study became subject to rumours and accusations of placenta being sold for mystical and financial gain by trial staff, leading to drop-out rates of 30% and the consequent halting of placental biopsy sampling in Benin. This paper explores the role of socio-cultural beliefs related to placenta and identified additional factors contributing these rumours., Methods: A qualitative comparative emergent-theory design was used to assess social factors related to trial implementation and uptake in the three countries. Data from participant observation, informal conversations, group discussions and interviews were triangulated and analysed with NVivo Qualitative Analysis software., Results: Despite similar sociocultural beliefs about the sacred nature of the placenta in all three study countries, these beliefs did not affect participation rates in Burkina Faso and The Gambia and placenta-related rumours only emerged in Benin. Therefore, the presence of beliefs is not a sufficient condition to have generated placenta-selling fears. The rumours in Benin reflected the confluence of placenta-related beliefs and factors related to the implementation of the trial (including a catalysing adverse event and miscommunication during the informed consent procedure). Furthermore, distinct socio-political factors contributed to the emergence of rumours, including the historical distrust in governmental organizations and the tense relationship between some of the actors involved in the trial., Conclusion: Transdisciplinary social science research designs should accompany the implementation of the trial. The integration of multiple stakeholders' knowledge and involvement is required to define and solve upcoming barriers.

Worldwide, cattle production is struggling to face the negative impacts caused by ticks and Rhipicephalus (Boophilus) microplus is one of the most harmful ticks for livestock. Most of the people in West Africa depend on cattle farming and subsistence agriculture. The presence of ticks on cattle is a major problem faced by smallholder farmers who fight for their livelihood. National and regional tick control programs could assist these rural communities in protecting their livelihoods against ticks and tick-borne diseases, but only if they take into account the targeted herders and their perception on cattle management and tick control. This paper aims to provide a better insight in the socio-economic characteristics of Beninese cattle farmers, and their perception on tick burden, as well as to document common tick control strategies. Different tick species and their seasonality are well understood by cattle herders. For tick control, many still use manual tick removal, especially in the north of the country. The high cost of acaricides, the lack of financial means of African farmers, and of the local stockbreeders in particular, limits the use of acaricides in livestock breeding in Benin. While aiming to increase the meat or milk production of their animals, stockbreeders who can afford it sometimes turn to an abusive use of acaricides, which might in time lead to an increase in tick resistance. This study remains one of the rare studies to report extensively on the perceptions of West African cattle herders.

Background: Ensuring equitable access to maternal health care including antenatal, delivery, postnatal services and fertility control methods, is one of the most critical challenges for public health sector. There are significant disparities in maternal health care indicators across many geographical locations, maternal, economic, socio-demographic factors in many countries in sub-Sahara Africa. In this study, we comparatively explored the utilization level of maternal health care, and examined disparities in the determinants of major maternal health outcomes., Methods: This paper used data from two rounds of Benin Demographic and Health Survey (BDHS) to examine the utilization and disparities in factors of maternal health care indicators using logistic regression models. Participants were 17,794 and 16,599 women aged between15-49 years in 2006 and 2012 respectively. Women's characteristics were reported in percentage, mean and standard deviation., Results: Mean (±SD) age of the participants was 29.0 (±9.0) in both surveys. The percentage of at least 4 ANC visits was approximately 61% without any change between the two rounds of surveys, facility based delivery was 93.5% in 2012, with 4.9% increase from 2006; postnatal care was currently 18.4% and contraceptive use was estimated below one-fifth. The results of multivariable logistic regression models showed disparities in maternal health care service utilization, including antenatal care, facility-based delivery, postnatal care and contraceptive use across selected maternal factors. The current BHDS showed age, region, religion were significantly associated with maternal health care services. Educated women, those from households of high wealth index and women currently working were more likely to utilize maternal health care services, compared to women with no formal education, from poorest households or not currently employed. Women who watch television (TV) were 1.31 (OR = 1.31; 95% CI = 1.13-1.52), 1.69 (OR = 1.69; 95% CI = 1.20-2.37) and 1.38 (OR = 1.38; 95% CI = 1.16-1.65) times as likely to utilize maternal health care services after adjusting for other covariates., Conclusion: The findings would guide stakeholders to address inequalities in maternal health care services. More so, health care programmes and policies should be strengthened to enhance accessibility as well as improve the utilization of maternal care services, especially for the disadvantaged, uneducated and those who live in hard-to-reach rural areas in Benin. The Benin government needs to create strategies that cover both the supply and demand side factors at attain the universal health coverage.

Introduction: This paper is based on two observations. First, despite multiple health programmes, access to services and quality of obstetric care remain inadequate in Africa. Secondly, although several qualitative studies have described the poor quality of admission facilities, violence during delivery and neglect of the poorest women, the reasons behind these behaviours have not been elucidated.This survey, conducted in Benin and Burkina Faso, examined midwives' experiences of their job, their obstetric practices and their lives.By including the emotional, sensorial, linguistic and social elements, this paper shows important discordances between the proposals made by programmes (installation in rural areas, strict financial management) and midwives' social and emotional duties and economic roles. It highlights the importance of gender relations in the careers of these professionals.The study also shows that the attitudes of midwives are related to the fact that childbirth is considered to be a moral act and their mistreatment behaviour corresponds to constant shifts between technical skills (fertility) and value judgements concerning expression of pain, sexuality and desire. On the other hand, midwives justify their violent practices by the urgency of the situation, especially during childbirth.The provision of care and effective implementation of programmes cannot be improved without taking into account these forms of justification and without constructing dialogues enabling midwives to develop a reflection about their social and emotional constraints, their relation to sexuality, and the reasons for their actions.

This paper presents the overview of the legal and institutional frameworks of research with human beings in sub-Saharan Africa, in particular in Benin, Cameroon and Nigeria. Concerning the methodology, a literature review focused on the regulations of institutional frameworks was done. Then, 28 semi-structured interviews were conducted with members of ethics committees to assess their composition and their mode of operation. Finally, we describe the existing courses in research ethics included in programs of first, second and third cycles in major universities from concerned countries.Concerning structures, all countries have normative and functional ethics committees concerned with the basics of ethics in health research. However, these ethics committees face several challenges including the lack of funding, deficiencies in the training of their members and the application of the ethical evaluation to qualitative and mixed researches.

Background: Few detailed facility-based costing studies of routine immunization (RI) programs have been conducted in recent years, with planners, managers and donors relying on older information or data from planning tools. To fill gaps and improve quality of information, a multi-country study on costing and financing of routine immunization and new vaccines (EPIC) was conducted in Benin, Ghana, Honduras, Moldova, Uganda and Zambia., Methods: This paper provides the rationale for the launch of the EPIC study, as well as outlines methods used in a Common Approach on facility sampling, data collection, cost and financial flow estimation for both the routine program and new vaccine introduction. Costing relied on an ingredients-based approach from a government perspective. Estimating incremental economic costs of new vaccine introduction in contexts with excess capacity are highlighted. The use of more disaggregated System of Health Accounts (SHA) coding to evaluate financial flows is presented., Results: The EPIC studies resulted in a sample of 319 primary health care facilities, with 65% of facilities in rural areas. The EPIC studies found wide variation in total and unit costs within each country, as well as between countries. Costs increased with level of scale and socio-economic status of the country. Governments are financing an increasing share of total RI financing., Conclusions: This study provides a wealth of high quality information on total and unit costs and financing for RI, and demonstrates the value of in-depth facility approaches. The paper discusses the lessons learned from using a standardized approach, as well as proposes further areas of methodology development. The paper discusses how results can be used for resource mobilization and allocation, improved efficiency of services at the country level, and to inform policies at the global level. Efforts at routinizing cost analysis to support sustainability efforts would be beneficial., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Buruli ulcer (BU) is an infectious disease caused by Mycobacterium ulcerans. Benin, one of the most severely affected countries, notified 365 cases in 2012. This article presents the results of a psychosocial and behavioural survey conducted in the context of a health promotion (HP) project with community participation. This paper describes the diagnosis, prevention, behaviours, as well as perceptions and experiences related to BU., Methods: A cross-sectional study was conducted in two villages (Azonme, Houedota) of Benin Atlantic department. From 15 May to 19 June 2011, a volunteer survey was conducted with 15 former patients and 15 new patients, selected by purposive sampling and 30 randomly selected healthy individuals. Encoding and data analysis were performed with SPSS and Excel., Results: Respondents were aged 11 to 100 years with a mean age of 36.63 years and 55% were men. More than 96% of respondents were aware of BU (symptoms, mode of transmission, prevention and treatment). % were familiar with the mode of transmission, but were not aware of preventive measures. Twenty-none of the 30 patients or former patients were treated in hospital. The attributed and perceived (including non-medical) causes of the disease were water (52), bacteria (17), bad luck (5). 92% of respondents were satisfied with the services of health professionals but proposed changes (46) concerning hospital accessibility and cost of care., Discussion: These results show similarities and differences compared to those reported in the literature on the subject. These surveys were the basis for health promotion interventions with the participation of two communities.

The logistics and cost of environmental monitoring can represent challenges for heritage managers, partly because of the sheer number of environmental parameters to consider. There is a need for a system, capable of monitoring the holistic impact of the environment on cultural materials while remaining relatively easy to use and providing remote access. This paper describes a dosimetric system based on piezoelectric quartz crystal technology. The prototype sensing module consists of an array of piezoelectric quartz crystals (PQC) coated with different metals (Fe, Cu, Ni and Sn) and includes a temperature and relative humidity sensor. The communication module involves an 802.15.4 low-power radio and a GPRS gateway which allows real time visualisation of the measurements online. An energy management protocol ensures that the system consumes very low power between measurements. The paper also describes the results and experiences from two heritage field deployments, at Apsley House in London, UK, and at the Royal Palaces of Abomey in Benin. Evaluation of PQC measurements, temperature, relative humidity and the rate of successful transmission over the communication systems are also reported.

This paper questions the current highlighted question of "fake drugs" in the media and through institutional speeches. After a brief reminder of the expressions used previously in France and in the French-speaking countries of West Africa, the realities which recover various phenomena will be discussed as well as the hotchpotch often made between them: the phenomenon of counterfeit drugs, that of substandard medicines and the recently legally defined in Europe phenomenon of falsified drugs. Then, the data of an anthropological study led from 2005 till 2007 about the informal market of pharmaceutical in Benin will allow to underline the differences which exist between this phenomenon and that of counterfeit drugs as well as that of falsified drugs. Finally, the political and economic stakes which recover these questions will be highlighted and will explain why "fantasized" speeches are often given about them. The conclusion will stop on the problem of substandard medicines and some of the ways to solve it will be sketched.

Background: In October 2012, the Meningococcal A conjugate vaccine MenAfriVac was granted a label variation to allow for its use in a controlled temperature chain (CTC), at temperatures of up to 40°C for not more than four days. This paper describes the first field use of MenAfriVac in a CTC during a campaign in Benin, December 2012, and assesses the feasibility and acceptability of the practice., Methods: We implemented CTC in one selected district, Banikoara (target population of 147,207; 1-29 years of age), across 14 health facilities and 150 villages. We monitored the CTC practice using temperature indicators and daily monitoring sheets. At the end of the campaign we conducted a face-to-face survey to assess vaccinators' and supervisors' experience with CTC., Findings: A mix of strategies were implemented in the field to maximize the benefits from CTC practice, depending on the distance from health centre to populations and the availability of a functioning refrigerator in the health centre. Coverage across Banikoara was 105.7%. Over the course of the campaign only nine out of approx. 15,000 vials were discarded due to surpassing the 4 day CTC limit and no vial was discarded because of exposure to a temperature higher than 40°C or due to the Vaccine Vial Monitor (VVM) reaching its endpoint. Overall confidence and perceived usefulness of the CTC approach were very high among vaccinators and supervisors., Interpretation: Vaccinators and supervisors see clear benefits from the CTC approach in low income settings, especially in hard-to-reach areas or where cold chain is weak. Taking advantage of the flexibility offered by CTC opens the door for the implementation of new immunization strategies to ensure all those at risk are protected., (Copyright © 2014. Published by Elsevier Ltd.)

Introduction: Infant and young child (IYC) growth impairment remains a public health problem in Africa partly because infants are exposed to staple foods (contaminated with mycotoxins) at an early age. Understanding the role of mycotoxins in IYC growth is vital, and this paper systematically reviews the available knowledge., Methods: Studies were searched and included if they provided information on African IYC mycotoxin exposure rates and/or growth. Studies were excluded if subjects were older than 15 years, if they were animal studies or focusing on other mycotoxins. Relevant search words were included in search strings. Eight reviews were identified and reference lists scrutinised for additional studies., Results: Ten studies were included; 8 focused on aflatoxin (AF), 2 on fumonisin (FB) and none on deoxynivalenol (DON) and zearalenone (ZEA). AF exposure prevalence reached 100% with levels at 40.4 pg/mg. AF was present in umbilical cords indicating that AF crosses the placenta. Maternal exposure levels were correlated with breast milk levels. The highest levels of serum AF (mean 32.8 pg/mg) were measured in Benin and Togo with 5.4% reaching levels higher than 200 pg/mg. At the end of weaning, children had similar prevalence and exposure levels as adults. RESULTS also indicated that infants with higher levels of maternal exposure had significantly lower height-for-age z-scores (HAZ scores), although there was no significant association between cord AF and infant HAZ scores or AF in cord blood and HAZ scores. Significantly higher mean maternal AF levels related to lower weight-for-age z-scores (WAZ scores) were reported, and infants with higher levels of maternal exposure had significantly lower WAZ scores that decreased over age. Cord AF levels had no effect on infant WAZ scores. One study investigated the association between FB and IYC growth and found that those with FB intakes greater than the provisional maximum tolerable daily intake were significantly shorter (1.3 cm) and lighter (328 g). No studies investigated the role of DON and ZEA., Conclusion: A limited number of epidemiological studies have been conducted, and available research indicates extreme exposures to AF. There are strong associations between AF exposure and stunting and wasting. However, more epidemiological research is urgently needed to understand the role of FB, DON and ZEA in IYC growth., (© 2014 S. Karger AG, Basel.)

Background: Microscopic examination of stained thick blood smears (TBS) is the gold standard for routine malaria diagnosis. Parasites and leukocytes are counted in a predetermined number of high power fields (HPFs). Data on parasite and leukocyte counts per HPF are of broad scientific value. However, in published studies, most of the information on parasite density (PD) is presented as summary statistics (e.g. PD per microlitre, prevalence, absolute/assumed white blood cell counts), but original data sets are not readily available. Besides, the number of parasites and the number of leukocytes per HPF are assumed to be Poisson-distributed. However, count data rarely fit the restrictive assumptions of the Poisson distribution. The violation of these assumptions commonly results in overdispersion. The objectives of this paper are to investigate and handle overdispersion in field-collected data., Methods: The data comprise the records of three TBSs of 12-month-old children from a field study of Plasmodium falciparum malaria in Tori Bossito, Benin. All HPFs were examined systemically by visually scanning the film horizontally from edge to edge. The numbers of parasites and leukocytes per HPF were recorded and formed the first dataset on parasite and leukocyte counts per HPF. The full dataset is published in this study. Two sources of overdispersion in data are investigated: latent heterogeneity and spatial dependence. Unobserved heterogeneity in data is accounted for by considering more flexible models that allow for overdispersion. Of particular interest were the negative binomial model (NB) and mixture models. The dependent structure in data was modelled with hidden Markov models (HMMs)., Results: The Poisson assumptions are inconsistent with parasite and leukocyte distributions per HPF. Among simple parametric models, the NB model is the closest to the unknown distribution that generates the data. On the basis of model selection criteria AIC and BIC, HMMs provided a better fit to data than mixtures. Ordinary pseudo-residuals confirmed the validity of HMMs., Conclusion: Failure to take overdispersion into account in parasite and leukocyte counts may entail important misleading inferences when these data are related to other explanatory variables (malariometric or environmental). Its detection is therefore essential. In addition, an alternative PD estimation method that accounts for heterogeneity and spatial dependence should be seriously considered in epidemiological studies with field-collected parasite and leukocyte data.

This paper describes the first African experience with the Nutrition-Friendly School Initiative (NFSI) in two large West African cities: Ouagadougou, Burkina Faso and Cotonou, Benin. NFSI was launched by the World Health Organization (WHO) and its partners in 2006, as a means of preventing the double burden of malnutrition: the coexistence of undernutrition and overnutrition among school-children. NFSI pilot-testing is one component of the Partnership Project on the Double Burden of Malnutrition, funded by the Canadian International Development Agency for 6 years (2008-2014). The Project assisted the government in the selection of pilot schools, fostered the installation of health and nutrition committees in selected schools, and helped with the initial school self-assessments. In accordance with the empowering philosophy of health promotion, pilot schools did not follow a pre-defined schedule of interventions, except for the training of teachers in nutrition education and the nutritional (anthropometric) surveillance of schoolchildren. For the latter activities, technical assistance and seminal funds were provided. Yearly planning workshops were held for school committees, with WHO support. In both settings, training was given to street vendors in order to improve the hygiene and nutritional value of food sold to schoolchildren. Other activities included special nutrition events and sanitation measures. In both cities, NFSI showed promising results in terms of school and community mobilization towards improved nutrition and health; however, NFSI must be better understood as an endogenous and self-sustaining approach. Furthermore, household poverty and scarce school resources appear as major barriers to gaining full impact of NFSI in low-income populations.

Sexual partner homophily is the tendency of individuals to choose partners similar to themselves. The extent and nature of partner homophily influences the structure of sexual networks and hence the spread of sexually transmitted infections (STIs). In this paper, we compare homophily by ethnicity, age and educational status in representative populations from five African cities in Benin (Cotonou), Cameroon (Yaounde), Kenya (Kisumu), Zambia (Ndola) and South Africa (Carletonville). We find low rates of homophily by age and high rates for educational status throughout the region. There is a large variation in homophily by ethnicity between these five cities, with rates lowest in Ndola. In Carletonville, there is a gendered difference in homophily by ethnicity. We discuss the possible implications these variations in the extent and type of homophily may have for STI transmission in the region.

The aim of this study was to determine the genetic diversity of Plasmodium falciparum by analyzing the polymorphism of the msp-1 and msp-2 genes and the multiplicity of infection in children with uncomplicated malaria in southern Benin. Blood samples of children with fever or history of fever with thick smear positive P. falciparum were collected on filter paper. After extraction of DNA by Chelex®, the samples underwent nested PCR. 93 isolates from children were genotyped. For the msp-1 gene, the K1 and R033 sequences were the most represented in the study population with 85.2% and 83% prevalence, respectively. Regarding the msp-2 gene, the FC27 family was more highly represented with 99% prevalence against 81.5% for 3D7. Mixed infections accounted for 80.4% of the samples. Twenty-five alleles were identified for msp-1 and 28 for msp-2. Fourteen and ten alleles belonged to the K1 (100-500 bp) and MAD20 (100-500 bp) families, respectively. The RO33 sequence did not show any polymorphism, with only one variant (160 bp) detected. The msp-2 gene was present as 16 FC27 family fragments (250-800 bp) and 12 of the 3D7 family (350-700 bp). The multiplicity of infection was estimated at 3.8 for msp-1 and 3.9 for msp-2 with 77 (87.5%) and 84 (91.3%) samples harboring more than one parasite genotype for msp-1 and msp-2, respectively. The multiplicity of infection (MOI) was influenced neither by age nor by parasite density. This study shows a significant diversity of P. falciparum in southern Benin with an MOI unaffected by age or by parasite density., (© A. Ogouyèmi-Hounto et al., published by EDP Sciences, 2013.)

One of the problems in health care in developing countries is the bad accessibility of medicine in pharmacies for patients. Since this is mainly due to a lack of organization and information, it should be possible to improve the situation by introducing information and communication technology. However, for several reasons, standard solutions are not applicable here. In this paper, we describe a case study in Benin, a West African developing country. We identify the problem and the existing obstacles for applying standard ECommerce solutions. We develop an adapted system approach and describe a practical test which has shown that the approach has the potential of actually improving the pharmaceutical care delivery. Finally, we consider the security aspects of the system and propose an organizational solution for some specific security problems.

This paper explores the social and institutional processes that constrain and enable obstetric patients in Benin to critically evaluate quality of healthcare and to stimulate positive changes in the health system. Based on qualitative data collected as part of a hospital auditing system, the paper analyses semi-structured patient feedback interviews and their function as a primary mechanism through which critical patient evaluation can develop constructively. Using a Bourdieuan framework, we explore the dynamic social conditions that give rise to transformative agency and institutional change. Our results show that hospitals are often permeated with the habitus of employment, kinship and reproductive social fields, through which a number of social, economic and healthcare conflicts, power struggles and blame-inducing interactions emerge. These conflicts generally serve to keep patients quiescent and passive when it comes to developing critical statements of quality of care. In a subset of cases, however, these conflicts are transformed by patients and their family members into opportunities for modifying the values and practices of each habitus in new and creative ways. The active negotiation of social conflict and blame enabled a minority of patients actively to divert blame from themselves and to develop and maintain critical healthcare evaluations.

To be successful, initiatives to improve smallholder's goat production should directly address the needs and objectives of the keepers while promoting rational use of local genetic resources. This paper identifies the objectives, constraints and needs of goat farmers in southern Benin and discusses their relevance to the development of improvement programmes. Between November and December 2005, structured questionnaires, focus group discussions and participant observation were used to collect information from 38 goat farmers in two selected locations. Goats were kept mainly for sale whenever cash was needed. Traits related to reproduction, to behaviour, to health and to meat production were considered equally important and were ranked very highly by goat keepers. Increased net income per flock through increased number of marketable animals is the derived breeding objective from the trait analysis. Disease outbreaks resulting in high mortality, poor housing, and feed shortages were, in descending order, the most important problems. It was concluded that the development of initiatives to improve management practices is an overriding priority. It will lead to increases in productivity in the short term and foster farmers' participation in the development of long-term improvement strategies, which should include selection and controlled mating.

Nearly half the world's population lacks basic sanitation to protect their environment from human fecal contamination. Building a latrine is the first step on the sanitation ladder in developing countries where a majority of the population defecates in open or public areas. Public health programs to improve sanitation have consistently framed promotional messages in terms of fecal-oral disease prevention and largely fail to motivate changes in sanitation behavior. A qualitative consumer study using in-depth interviews with 40 household heads was carried out to explore the decision to install a pit latrine in rural Benin. The motives for installing a latrine are reported and variations across the interviews are examined. The paper asserts that at least one active drive (desire for change or dissatisfaction) from among 11 found is needed to motivate latrine adoption. Drives involved prestige, well-being, and situational goals. Health considerations played only a minor role, and had little if anything to do with preventing fecal-oral disease transmission. Drives varied with gender, occupation, life stage, travel experience, education, and wealth, and reflected perceptions of the physical and social geography of the village, linked to availability of open defecation sites, social structure, road access, and urban proximity. The results have broad implications for new messages and strategies to promote sanitation in developing countries.

Malaria represents a major health problem with over 1 million annual deaths in Africa alone. There are a limited number of policies tackling the health problems of people at greater risk, namely the poor and rural communities. This is partly due to the lack of evidence available on the range of factors affecting their health status. Despite endemic malarial situations, there is still little understanding of the relative importance of economic factors that contribute to people acquiring malaria. This paper examines the socio-economic and economic factors that affect the incidence of malaria in rural community households in Benin, where malaria is endemic. A sample of 1585 households was determined to collect information on socio-economic characteristics and the presence of malaria symptoms. Probit estimation techniques were used to assess the impact of socio-demographic and socio-economic factors on the incidence of malaria, comparing households with and without malaria patients. Predisposing characteristics of the household head such as age, knowledge of malaria, education and the size of the household significantly affect the incidence of malaria as anticipated by economic theory. Enabling factors reflecting higher economic status, measured by monthly expenditure and a socio-economic index, have a statistically significant and positive impact on the incidence of malaria. This could reflect that better-off have improved case reporting and are likely to seek treatment. Variations in socio-economic and economic characteristics are significant in explaining the incidence of malaria, even in an endemic malarial setting.

This paper estimates the total cost to women and their families associated with a spontaneous vaginal delivery and five types of 'near-miss' obstetric complication in Benin and Ghana, and assesses affordability in relation to household cash expenditure. A retrospective evaluation of costs was carried out among 121 mothers in three hospitals in Ghana. A prospective evaluation of costs was undertaken among 420 pregnant women in two hospitals in Benin. Information was collected on the cost of travel to the facilities and of direct medical and non-medical costs incurred during their stay in hospital. In Benin, costs ranged from an average of 15 US dollars for a spontaneous delivery to 256 US dollars for a near-miss complication caused by dystocia. In Ghana, average costs ranged from 18 US dollars for a spontaneous vaginal delivery to 115 US dollars for a near-miss complication caused by haemorrhage. Medical costs accounted for the largest share of total costs, mainly drugs and medical supplies in Ghana and costs of the delivery and any surgical intervention in Benin. Payments associated with a spontaneous vaginal delivery amounted to at least 2% of annual household cash expenditure in both countries. In the case of severe obstetric complications, costs incurred reached a high of 34% of annual household cash expenditure in Benin. The economic burden of hospital-based delivery care in Ghana and Benin is likely to deter or delay women's use of health services. Should a woman develop severe obstetric complications while in labour, the relatively high costs of hospital care could have a potentially catastrophic impact on the household budget.

In developing countries, the usual modelling of the correlates of health problems is not a good fit for the health phenomena encountered and the available data. Indeed, three common situations occur: (a) it is often the observed symptoms that are used to determine medical interventions instead of specific disease diagnostics or general health indicators; (b) the ill persons described by the data are often affected by multiple health problems; and (c) the correlates of the full spectrum of all symptoms need to be considered together. In this paper, these issues are dealt with by proposing a statistical approach based on competing scores of symptoms that explain their relative prevalence among the observed ill persons. Using multinomial logit models, the relative prevalence of four symptoms was estimated for four age classes of ill persons in Benin. Socio-demographic characteristics, household equipment and consumption behaviour are shown to influence the relative prevalence of symptoms and therefore could be used to decide what treatment to use. Moreover, living standards and economic activities are important and the pattern of symptoms among poor or agricultural ill persons differs from that of the rich or the non-peasants. The proposed method can be used to assist the definition of target groups and to guide the allocation of scarce resources in poor countries.

"AFIP classification" by light microscopy was of help to analyze the skin lesions of Buruli ulcer, in which the histopathology were classified into 6 stages i.e. active, healing, active but healing, consistent with active and chronic stages. In this paper, skin lesions biopsied from 41 cases of Buruli ulcer were observed by light microscopy. Those were sent from Benin in west Africa at 1997, and under the control of Armed Forces Institute of Pathology(AFIP) in Washington DC, USA. Each age, sex, biopsy lesions and histopathological stage and corresponding characteristic histopathological findings of 41 cases except that of chronic stage were analyzed and herewith reported by this paper.

In Benin, a Francophone country in West Africa, maternity mortality has been estimated at between 473 and 990 deaths per 100,000 live births. Yet 92 per cent of women gave birth in either a public or private health centre, and almost all of them received antenatal care. This paper reports on an exploratory, qualitative study in 1995, among 19 women aged 20-40 who had recently given birth in a referral hospital, of their experiences of antenatal and emergency obstetric care, as part of a larger study on measuring the prevalence of severe maternal morbidity in the community. Thirteen of the women had had obstetric complications and 11 had had a caesarean section. Pregnancy was described as a period of great vulnerability, and feelings of insecurity and fear of death were omnipresent in the women's accounts. Their primary motivation for seeking antenatal care was the appearance of symptoms or events they perceived as abnormal. Although a minority were lucky enough to have a kind midwife, many complained about not being able to ask questions or get any explanations, being mistreated and humiliated by health personnel and described the anguish they felt in the face of medical procedures they did not understand, especially caesarean section, which they were told were necessary to save their lives. Access to emergency obstetric care is a priority in the battle against maternal mortality, but it cannot be at the expense of improvements in the quality of the interaction between women and health personnel. The inclusion of women's voices in the objectives of safe motherhood programmes is necessary to better serve women's needs.

Impregnated bednets can be considered a major tool for reducing Anopheles bites, malaria morbidity and overall mortality. The resistance of Anopheles gambiae to pyrethroids used to impregnate bednets and curtains has already been noted in the urban area of Cotonou in Benin (18, 21). In this study, we wished to find out if the resistance observed in Cotonou is localized only in this town or is already extensive throughout Benin. In this case, such resistance would be a handicap to the promotion of impregnated bednets in Benin. The study was carried out in 15 localities throughout the different ecological zones of Benin. The study has also taken into account environmental factors favouring the emergence of resistance. We did susceptibility tests with WHO test kits for adult mosquitoes using impregnated papers. The papers were impregnated with permethrin 0.25%, deltamethrin 0.025% and lambdacyhalothrin 0.1%. We also tested DDT 4% to find out if there was a cross resistance between DDT and the pyrethroids. Two mosquito species were tested: An. gambiae and An melas. In northern Benin, where farmers use insecticides against cotton pests, vectors are susceptible to deltamethrin and lambdacyhalothrin and resistant to permethrin. In the south, An. gambiae is resistant to deltamethrin and permethrin. This resistance is high in the urban zone of Cotonou, in the coastal and lagoon areas and at Kraké, a frontier viliage with Nigeria. The resistance observed in southern Benin is confirmed by the lengthening of the knock-down time of mosquitoes which were exposed for 1 hour to insecticide in impregnated WHO test tubes, and by a reduction of permethrin and deltamethrin remanence effect.

The analysis of health policy reform focuses mostly on the contents of reforms. Walt and Gilson (1994) draw attention to the fact that the environmental context as well as the actors involved are of crucial importance to the process of policy adoption. This paper describes and analyses the process of adoption of the new concept of so-called 'sanitary zones' in the Republic of Benin as part of the health sector reform. The analysis of the reform is based on the examination of documents and interviews carried out in Benin in February 1997. The main findings show that the reasons for the specific policy choice do not emerge clearly. The main problems identified are: the role of the hospital, the incongruous administration, resistance against the reform and the question whether the government actually has the political will to change. Possible solutions to these constraints are offered in the conclusion.

The HIV/AIDS threat continues in African countries, including the Republic of Benin, during this period of economic crisis which is accentuated by the devaluation of the currency. National statistics from the Ministry of Health indicate a progression of the number of cases seropositive for HIV and the number of cases developing AIDS. Concomitantly, we observe a decrease of the number of teenagers fearing HIV infection and a spread or risky sexual behavior, such as unprotected sex. Despite the weak prevalence of HIV infection in Benin, the increase of the number of cases with AIDS remains a serious social problem. This paper describes the epidemiological pattern of AIDS and its social, demographic and economical implications as they affect the current national program to increase the awareness of the problem. We obtained scientific information on the epidemiological chain of AIDS morbidity from prior research results, data from the disease control centers and interviews with the parents of some patients. Quantitative data was collected from twenty selected disease control centers of the national program against AIDS from 1986 to 1995. We compared these data with data obtained by the WHO from 1986 to 1992 from the neighboring countries of Benin. We observed an exponential growth of the cumulative number of AIDS cases, from one declared case in 1985 to 1,280 cases in 1995, including twenty thousand cases seropositive for HIV in 1991. The majority of cases were people between 20 and 49 years old and were predominantly males. Heterosexual (73%), homosexual (0.8%), and mother to child vertical transmission were the principal modes of transmission registered for carriers of HIV-1, HIV-2, or both. The qualitative study revealed a social situation dominated by verbal violence against infected women, absenteeism at work of the patients' family and, friends and a psychological impact on the children of the patients. An evaluation of the direct costs of AIDS was estimated to be $217,600 (US $) for the 1,280 reported cases. We suggest further reinforcement of the program to raise the awareness of the young people in the urban and rural areas of the country.

In 1966, nineteen countries of West and Central Africa began a regional smallpox eradication and measles control programme in cooperation with the World Health Organization. This paper summarizes sample survey data collected to assess the results of the programme in Northern Nigeria (Sokoto and Katsina Provinces), Western Nigeria, Niger, Dahomey, and Togo. These data indicate that the programme, which used mass vaccination campaigns based on a collecting-point strategy, was generally successful in reaching a high proportion of the population. Analysis of vaccination coverage and vaccination scar rates by age underlined the importance to the programme of newborn children who accumulate rapidly following the mass campaign. Of all persons without vaccination scars at the time of the surveys, 34.4% were under 5 years of age; in the absence of a maintenance programme, this figure would rise to 40% after 1 year.