[Study of the contributing factors to home delivery (Senegal)]. / Etude des facteurs contributifs de l'accouchement à domicile (Sénégal).

In Senegal, 38% of deliveries occur at home. We believe that preparation for childbirth, informing women about the place of birth and the person who will assist in delivery, and the necessity of saving money in case of complications, can reduce deliveries at home. The purpose of this study is to determine the impact of preparation for delivery on place of delivery in Senegal. Matching was done on the preparation for delivery by the propensity score using the R package Matchit. A conditional logistic regression was used to analyze the relationship between preparation for birth and place of birth. The data were collected in 2006 from a sample of 3,093 women aged 15 to 49 years, mothers of children from 0 to 23 months in 5 regions of Senegal. The average age of women was 26.3 years (±6.6). The prevalence of delivery at home was 0.33 and 0.31 were given a preparation for childbirth. The following factors were associated with childbirth at home: preparing for the birth (OR: 0.36, CI 95%: [0.28-0.45]), at least primary school (OR: 0.59, CI 95%: [0.46-0.74]), number of prenatal care >3 (OR: 0.40, CI 95%: [0.29-0.54]) and early prenatal care (OR: 0.69 [0.51-0.83]). The relation with the profession of the person who performed the prenatal consultation was of borderline significance (P = 0.06). Particular emphasis should be placed on the preparation of delivery, especially during prenatal consultations.

[Traditional healers in the fight against HIV/AIDS infection in the health district of Fada N'Gourma (Burkina Faso)]. / Enquête sur le rôle des tradipraticiens de santé dans la lutte contre l'infection VIH/sida au Burkina Faso.

The purpose of this study was to evaluate collaboration between traditional healers (TH) and registered nurses (RN) in the care of people living with HIV (PLHIV) in the health district N'Gourma Fada, Burkina Faso. A survey was conducted among 26 RN, 33 TH working in the health district and 96 PLHIV under treatment at the Fada N'Gourma Regional Hospital. Survey data showed that only 9.1% had sound knowledge about HIV/AIDS and 18.2% about prevention methods. Conversely 84.8% had a good knowledge about clinical manifestations. Among TH, 84.8% claimed to refer patients to health facilities that provided no support for HIV/AIDS, 51.1% called for establishment of a framework of cooperation and 21.2% asked for reciprocity. Among nurses, 85.2% did not consider TH as part of the health community fighting against HIV/AIDS. Proposals focused on association of TH, frameworks of cooperation, and coordination of TH activities in the fight against HIV/AIDS.

[Annual assessement of a mobile ultrasonography service in the region of Ziguinchor, Senegal]. / Bilan d'activité annuel de l'echographie en stratégie avancée dans la région de Ziguinchor (Sénégal).

To provide rural populations with access to ultrasound scanning, a mobile ultrasound service was set up in the health districts of Sédhiou, Oussouye, Bignona and Ziguinchor in Casamance, Senegal. In 2001 the mobile unit performed a total of 56 missions and provided examinations to 1273 patients. The main indications were pregnancy assessment, amenorrhea, detection of pregnancy, painful pelvic tumors and hemorrhage. Findings allowed diagnosis of disorders in 25% cases. Disorders were pregnancy-related in 47% of cases and gynecological in 53%. Ultrasound examinations were performed for follow-up purposes in 15% cases, for therapeutic purposes in 24% and for referral to the regional hospital center in 61%. These findings demonstrate the utility of a mobile ultrasound service in managing health problems not only for the community but also for health-care structures. This service should be maintained until ultrasound equipment becomes available in district hospitals and personnel at those facilities have adequate training in ultrasound scanning.

[Analize of the determinants of microscopy's quality in the context of tuberculosis fighting within the health centers laboratories in Dakar Region]. / Analyse des déterminants de la qualité de la microscopie pour la lutte contre la tuberculose dans les laboratoires des Centres de Santé de la Region de Dakar.

INTRODUCTION: In order to improve the quality of the microscopy in the context of tracking and following-up the pulmonary tuberculosis patients, a study of the determinants of the quality of microscopy was carried out in the laboratories of the health centres in Dakar Region, Senegal. MATERIALS AND METHODS: We did an epidemiologic study, transversal type which proceeded during April 19th at May 05th, 2004. It consisted of a series of observations, interviews, review of the registers of laboratory and with a second reading and re staining, on the level of the National Laboratory of Reference of the National Programme of fight against Tuberculosis (LNR), of 50 blades collected blindly in the health centres of Dakar. RESULTS: It comes out from this study that there was no statistically significant link between the factors of risk of errors such as the overload of work, the bad condition of the microscope, the lack of competence and the errors observed in certain laboratories. On the other hand the aspect of the smears, the thickness of the smears and the presence of crystals could deteriorate the quality of microscopy because it was found that there was a statistically significant connection between the quality of microscopy and these various determinants. In addition we noted a good agreement of the results of these laboratories with those of the LNR (Kappa test = 0,981, p < 0,0001). CONCLUSION: According to these results, we recommend: a reinforcement of competences (training/recycling) regular of the laboratory assistants, and an installation of a system of quality control of microscopy, interns within the laboratories but also external by the National Laboratory of Reference.

[Costs of operation of an urban reinforced community health post (Senegal)]. / Analyse des coûts de fonctionnement d'un Poste de Santé renforcé en milieu urbain (sénégal).

INTRODUCTION: In Senegal, the public funding in community health post is low. Resources are mainly obtained from the sale of services. The aim of this study is to analyse the operating cost of a community health post and to propose a relevant tariffing that would assure sustainable activities. METHODS: We used the method of complete costs. It comes out from our study that the total cost is 20 870 920F. RESULTS: Wages represent 70% of total expenses, operating costs represent 27% and 4% are investment. The public funding represents a value of 12 257 325F (60% of the total) in which 88% correspond to expenses induced by civil servant wages. The health committee participates for 33% and the other participants (7%). CONCLUSION: At the end of our study, a sustainable and social tariffing, was proposed.

[Allergy to latex gloves among healthcare workers in Dakar]. / Allergie aux gants en latex chez les professionnels de la santé à Dakar.

BACKGROUND: The prevalence of latex allergy is high (to 17%) among groups at risk such healthcare workers. Our aim was to determine the prevalence and severity of allergy to latex gloves among health workers in Dakar. PATIENTS AND METHODS: The study was conducted in three of the five hospitals in Dakar (Senegal). A randomized sample was constituted. All healthcare workers required to use latex gloves in their work were included. A questionnaire was administered. The analysis was performed using the Epi-info software package (6.0). RESULTS: One hundred and forty cases were included. The median age was 39 years and the sex-ratio was 0.57. Sixty-six (47%) cases had familial atopic dermatitis, 13 (9.6%) had atopic dermatitis, and 4 (2.9%) indicated food allergy (banana, avocado). Irritant dermatitis was found in 40.7% of cases, 112 healthcare workers (81.2%) used bleach and water to clean their hands. Antiseptics were used frequently: 75.5% of those interviewed used them more than three times a day. None of the healthcare workers indicated any allergy to latex condoms. Otherwise surgical procedures and bladder/rectal catheters were noted respectively in 24% and 18% cases. Fifteen healthcare workers (10.7%), of whom 12 were women, indicated appearance of clinical signs when using latex gloves. The clinical manifestations were: contact urticaria or immediate pruritus (8 cases), combined contact dermatitis and contact urticaria (2 cases), allergic conjunctivitis (1 case), allergic rhinitis (2 cases) and asthma (2 cases). We also noted 6 cases of contact dermatitis. Rechallenge tests were performed in 7 cases and were positive, 2/3 prick-tests and 1/4 patch-tests (standard European battery). The statistical analysis shows that allergy to latex gloves was significantly associated with atopy and irritant dermatitis (p<0.03). DISCUSSION: We found a prevalence of allergy to latex gloves of 11% among healthcare workers in Dakar, reflecting reports in the literature. The classical risk factors such atopic dermatitis and irritant dermatitis were found. The correlation between irritant dermatitis and frequent use of bleach and water mean that these practices should be eradicated since they play an important role in the development of contact urticaria and anaphylactic reactions.

[Prognosis of stroke in department of neurology of Dakar]. / Pronostic des accidents vasculaires cerebraux au service de neurologie de Dakar.

INTRODUCTION: The general objective of this study was to determine the morbid-mortality of stroke followed in the Department of neurology of Dakar. MATERIALS AND METHODS: This prospective and longitudinal studywas carried out from August 2003 at May 2005 and concerned 170 patients hospitalized or seen in external consultation for cerebral vascular accident confirmed by the cerebral tomodensitometry. All the patients were subjected to a protocol allowing determining the sociodemographic data, the therapeutic itinerary, the nature and the mechanism of stroke. The follow-up was monthly for 12 months. RESULTS: The patients were old 25 to 90 years. The mean age was 61 +/- 13 years. The sex-ratio is 0.68. The ischemic cerebral vascular accidents represented 64.7% against 35.3% for the hemorrhagic vascular accidents. In 71.7 the AVCH was related to arterial hypertension. For the AVCI, a cardiopathy emboligene was objectified in 16.36% of the cases. The HTA constituted the principal factor of risk and was observed in 63.53% of the cases. The mortality rate was 28.8% (between j0 and j30) and 50.6% at one year. The age constitutes a factor of bad prognosis. For the sex the statistical analysis shows a no significant difference (p = 0.703). The repetition of stroke constitutes a factor of bad prognosis. 52.4% of the patients having an antecedent of stroke had died precociously. Mortality was higher in the AVCH with p = 0.043. The existence of disorders of conscience of start constituted a factor of bad vital prognosis. Among the 84 survivors after one year of follow-up, 49 had found their functional autonomy and 35 kept after-effects. CONCLUSION: Stroke is responsible for a strong mortality. The advanced age, the repetition of cerebral vascular accident, the hemorrhagic nature of the cerebral vascular accident constitutes factors of bad vital prognosis.

[Monitoring and evaluation of health care programs in Subsaharian Africa]. / Monitoring et évaluation des programmes de santé en Afrique subsaharienne.

The monitoring and evaluation is usually the weakest component of health programs in sub-Saharan Africa, what is undermining the sustainability of funding. The problems are complex and the weaknesses of the health systems are reflected on the monitoring and evaluation of specific programs. This paper gives an insight of the problems faced during field missions for monitoring and evaluation. The steps for building the M&E system have been reviewed and keys points for implementation have been provided.

[Situation of the new cases of pulmonary tuberculosis with positive smears follow up in the reference center of District Center, Dakar]. / Problematique de la prise en charge des nouveaux cas de tuberculose pulmonaire a frottis positif au niveau du centre de reference du District Centre de Dakar.

INTRODUCTION: In order to assess the care conformity of the new cases of pulmonary tuberculosis with positive smear (TPF+) with the recommendations of the national program of fight against tuberculosis (PNT), a retrospective study on files has been made in January 1st to June 30, 2000 in the reference center of District Center, in Dakar, Senegal. METHOD: All the new cases of TPF+ were included. Were excluded the relapses, the re treatment after failure or interruption. Were successively studied: the socio-demographic characteristics, the patient's status, and the quality of the bacteriological and the therapeutic follow-up. RESULTS: According to the reports, 115 new cases were counted. In contrary, based on the registers, 109 new cases of TPF+ including 38 women and 71 men were counted. The follow-up gave, at the end, 58% of cure, 4% of finished treatment, 32% of abandon, 4% of failure and 3% of transfer. Discordances of the data between cards, registers and reports/rates are explained by the lack of rigour during the notification of these supports. This bad notification contributes to deteriorate the quality of the patient's follow-up, but also the quality of the cases notification. It resounds negatively on the national health information system. CONCLUSION: A qualitative survey among the providers and the abandoned treatment could be more interesting to better understand the problematic of the tuberculosis patients follow-up for the best dealt with.

[Knowledge and behaviours concerning HIV/AIDS infection among sex workers in Ziguinchor (Senegal)]. / Connaissances et pratiques concernant l'infection a VIH/SIDA chez les travailleuses du sexe a Ziguinchor (Senegal).

INTRODUCTION: The Human Immunodeficiency virus (HIV) and the Acquired Immunodeficiency Syndrome (AIDS) which it causes constitute one of the major concerns of these two last decades. In Senegal, 77000 people live today with the HIV. In 2002, 28.5% of sex workers in Ziguinchor were infected with HIV. Professional sex work is considered as a main determinant of HIV/AIDS propagation. The objective of this study is to assess knowledge, a ttitudes and behaviours concerning HIV/AIDS within this target group in order to formulate recommendations to improve ongoing activities in information, education and communication. METHOD: The study was cross-sectional, descriptive and analytic. It was set up at the Ziguinchor sexual transmitted diseases (STD) center. Between April 16th and May 2nd in 2003, 68 sex workers who visited the center were interviewed. Data was entered and analyzed with Epi Info 6.04d software. RESULTS: The level of knowledge of sex workers in Ziguinchor was satisfactory: 94% gave at least one mode of contamination, 98.5% knew one means of prevention and 81% gave at least one symptom of the disease. However 35.3% of them did not require the wearing of condom, either because of trust in their partners, because of ignorance of the risk, or because of the proposition of special prices. CONCLUSION: Among sex workers followed at STD center of Ziguinchor, the observed attitudes and behaviors don't match the knowledge level. Information campaigns, that focus on at-risk behaviours, as well as the orientation of research towards specific means for women to prevent infection, such as microbicides, would be critical tools for better fighting against the HIV/AIDS epidemic.

[Prevalence of antiphospholipid antibodies in patients with sickle cell disease]. / Prévalence des anticorps antiphospholipides au cours de la drépanocytose homozygote.

Structural abnormalities in erythrocyte membrane are more and more claimed as a determinant factor in the sickle cell disease pathogenesis. This being would have been provided by a new anionic phospholipids distribution and conformation. Phosphatidyl-serine exposing and phosphatidic acid enhancing would induce specific immunoglobulins synthesis. In this study, assessment of antiphospholipid antibodies prevalence was carried out among sickle cell trait patients (n = 35) and homozygous patients (n = 59) as compared to healthy subjects (n = 39). Antiphospholipid antibodies, assayed by ELISA procedure, were significantly higher among the homozygous patients than the sickle cell trait patients ones and highlighted as compared to healthy subjects. Pathologic data were only observed among homozygous patients. These specific antibodies, associated with thrombosis and haemolysis, would have constitute a morbid link and a therapeutic target of this sickness, dominated by homodynamic troubles.

[A new decision support tool in the campaign against maternal mortality: the Dystocia Risk Score]. / Un novel outil d'aide à la décison médicale dans la lutte contre la mortalité maternelle: le Score de Risque Dystocique (SRD).

At Ziguinchor Regional Hospital (ZRH) in Senegal, 80% of maternal deaths are associated with late referral of dystocia cases. The gynecology and obstetrics team of the ZRH, in collaboration with the teaching staff of the Institute of Health and Development (ISED), tried to find ways to combat maternal mortality and stillbirth, based on double-entry contigency tables and a logical framework. We developed a tool more elaborate than a simple decision tree: the dystocial risk score. This tool has three components: A column provides a list of eight characteristics to check for in the woman: history of cesarean section, limping, less than 150 cm in height, no living child, less than 18 years old, more than 35 years old, other risk factors, no risk factors. A horizontal section provides a checklist of possible outcomes of the pregnancy itself: obstacle praevia, precedence, noncephalic presentation, uterine length of over 35 cm, loss of amniotic fluid over 12 hours or more, other abnormalities, no abnormalities. A rectangular grid indicates the prognosis. This grid consists of three zones: a large blue zone (dangerous), a medium-sized grey zone (doubtful) and a small blue zone (hopeful). A positive DRS is obtained if there is at least one cross in the dangerous zone and/or at least two crosses in the doubtful zone. If these conditions are not fulfilled, the DRS is negative. A positive DRS indicates that the woman should be referred to a center specialized in obstetric emergency care. This tool was validated in a study of 376 pregnant women carried out over a period of six months. It was found to have a sensitivity of 83.6%, a specificity of 90.1%, a positive predictive value of 72.3% and a negative predictive value of 94.1%. The DRS is a simple, easy-to-use decision-making tool. The large-scale use of this tool (by midwives, chief nurses and health workers) would accelerate the identification of pregnant women with a high risk of dystocia. The timely referral of these women to specialized emergency obstetrics centers would increase the efficacy of care and would reduce the levels of maternal mortality and stillbirth.

[Smoking habits among physicians in Dakar]. / Le tabagisme parmi les médecins exerçant à Dakar.

A prospective cross-sectional study was conducted in March 1999 on the prevalence of smokers and smoking habits among physicians practicing in the Dakar region. The study population was composed of 163 physicians; 128 male (78.5%) and 35 female (21.5%). The prevalence of smokers was 27.6%. The average age of the smokers was 40.5 (+/- 6.2) years (extremes between 30 and 61 years) and an average duration of 18 (+/- 6.6) years in smoking. Men smoked more than women (93.9% versus 6.7%) with 56.4% of heavy smokers. Specialists represented 63.3% and generalists 36.4%. Initiating factors were stress (28.9%), circle of friends/acquaintances (24.4%), fashion (24.4%), pleasure (20%) and advertisements (2.2%). A little over 82% smoked in public places, 68.9% in their work places and 49.5% before children. The average time duration smoking was stopped followed by relapse was 15.7 (+/- 9.7) months. 97.7% of smokers manifested their intention to stop. Nicotine dependence according too the Fagerström questionnaire was average (37.9%), high (39.6%) and very high (12.6%). Smoking is a reality in the medical environment in Dakar. Specific campaigns aimed at physicians will be necessary to hope for a sustainable change in behavior and for a much more pronounced implication in the fight against tobacco addiction.

[An innovative training experience in public health at the Cheikh Anta Diop University of Dakar]. / Une expérience innovante d'enseignement de la santé publique à l'Université Cheikh Anta Diop de Dakar.

The Institute for Health and Development (ISED) at the University of Dakar, was created in 1987. Its mission is to fulfill the public health training needs of Senegalese health care professionals. ISED is responsible for a training program entitled "Certificat d'études Spéciales" (CES), the equivalent of a Masters of Public Health degree. The "CES" is a two-year program comprised of six modules, which last four months each. The ISED training approach stresses trainee responsibility above all. It is based on the trainee's professional tasks and is oriented toward the problems identified by the trainees themselves. In this sense it is highly adaptive and flexible. Each module is implemented in the same way; initially there is a 15 day residential phase for intensive theoretical courses, followed by an application period of 75 days in the trainee's work place, and then a final residential phase of 15 days for writing and presenting a technical report on the work in the field. This model allows trainees to bring together the theoretical and the practical. The trainers directly supervise each of these three phases. The two residential phases are conducted in the ISED training center, located in Mbour, 80 Km south of Dakar. 103 trainees are enrolled in the program in seven different classes. Of these trainees, 93 are health care specialists (85 physicians 7 pharmacists, 1 dentist). Ninety percent of previous graduates have been civil servants who work for the Ministry of Health in Senegal and the remaining 10% were from Burkina Faso and Togo. The training program is considered by all stockholders, beneficiaries, and relevant financial institutions, to be appropriate, beneficial and successful.

[Drug management at the level of the Psychiatry Department of the Fann University Hospital Center: problem and perspectives]. / La gestion des médicaments au niveau du Service de Psychiatrie du CHU de Fann: problématique et perspectives.

Health system in developing countries is facing difficulties due to lack of resources and poor management of the available ones reinforced by the economic crisis and the structural adjustment program since 1980. The situation will be worsened by the recent devaluation of the France CFA. The consequences are a permanent shortage of drugs, a decreased motivation of the health personnel with at the end the decrease of health services reliability. Teaching Hospitals, which are essential for the implementation of PHC, are facing such situation. Thus, a study was conducted at the Department of Psychiatry, Fann Hospital to analyse the process of drug management and to find out suitable solutions. The study, qualitative, showed that that the main problems encountered are: inexistence of management tools with inexploitable health information systems, insufficient budget allocated for drug purchase, selection of drug exclusively on brand name with a standard list unrenewed since 1986, weak drug delivery system, frequent stock-outs. Prescribers are unaware of available drug at the pharmacy. Patients are not informed about their diseases and the use of drugs prescribed. Therefore, adopting the EDP in Teaching Hospitals will help for better management of drug delivery.

[Evaluation of the financial participation of the users of 102 health services in 3 districts of Senegal]. / Evaluation de la participation financière des usagers dans 102 postes de santé de trois districts au Sénégal.

Primary Health Care (PHC) financing is today one of the major concern of public health system managers in developing countries. Their governments never allocated appropriate and sufficient resources to the sector of PHC. The external donors' funds are mostly allocated to short term PHC projects. They stop with the end of the projects. The undesirable consequences of that situation are well known. They are mainly related to a persistence of high rate of mortality and morbidity due to preventable diseases. To better address that situation the health ministers of the WHO african region adopted in September 1987 in Mali the Bamako alternative, to the country economical situation, for PHC services financing. It permitted to finance up to 80% of the recurrent costs of health system of Pikine department in 1980. In the three pilot districts where the Bamako initiative strategy has been tested: Podor, Matam and Bignona, all of the one hundred and two (102) health posts are self financed for their recurrent costs, since 1992.

[Prevalence of malnutrition in the Mbao Health District]. / Prévalence de la malnutrition dans le district sanitaire de Mbao.

Protein-energy malnutrition is a real health priority in developing countries specially in african ones. So, a cross-sectional study was conducted, from April 14 to July 28 1995, in the health district of Mbao in Senegal, to determine the prevalence of protein-energy malnutrition (PEM) in a population of children 0-5 year old utilizing the health center, for a curative care, an immunization, a growth monitoring. Anthropometric and sociodemographic data were collected and analysed using a microcomputer with WHO/CDC Epi Info 6.0. The index weight/age expressed on Zscore was used with comparison to NCHS/CDC/WHO population's international reference. Among 204 children, 89 (43.6%) present a PEM.51 (57.3%) are male. More than 60% of the children with PEM are 6-29 months old. 74 (83.2%) live in the surroundings of Mbao. They all come from different ethnic group. 67.4% utilize the health center for a curative care and 7.9% for growth monitoring. There is no relation statistically significant between protein-energy malnutrition and the parameters we studied. To overcome such problem, it is necessary to strengthen the management of malnourished children in specialized centers, to educate families in the nutritional properties of local products and to improve the socioeconomic status of the population for better access to these products.

[Dental cavities in the urban, suburban, and rural environment among school children from the region of Dakar]. / Etude de la carie dentaire en milieu urbain, sub-urbain et rural chez les écoliers de la région de Dakar.

An epidemiological survey on 2.067 children from 7 to 12 years old in average carried in three urban, suburban and rural school environments, has shown that dental caries prevalence is not yet alarming in the district of Dakar, and that the caries index remain more high in the urban environment than in the rural environment. However face to the urbanization and the industrialization of this region, the modification of the alimentary habits appear to be facilitating factors of the raising of the dental caries prevalence in the coming years if nothing is done. It's why preventive measures have to be taken based over all on dental health education and dental health information in organized structures like school.

[Prevalence of the use of skin bleaching cosmetics in two areas in Dakar (Sénégal)]. / Prévalence de l'utilisation de produits cosmétiques dépigmentants dans deux quartiers à Dakar (Sénégal).

The use of skin bleaching cosmetics is an increasingly widespread phenomenon in Africa. If the negative sanitary effects of this practice are today well known, reliable statistics on the importance of the problem within the global population are rare. Our study, conducted in two popular areas in Dakar, Usine bene taly and Usine Niary Taly, had 2 objectives: to determine the prevalence of the use of skin bleaching cosmetics in the studied zones, to describe the prevalence according to the following variables: age, matrimonial situation, level and/or type of instruction, job, type of agents used. For that purpose, we conducted a transverse study on a representative sample of 600 women from 15 to 55 years old. This study reveals a prevalence of the use of skin bleaching cosmetics of 67.2%. The agents found are hydroquinone derivatives (61%), topical corticosteroids (37%) and agents from unknown origin (2%). The use of skin bleaching cosmetics is more important among young women between 30 to 44 years (72.5%), married (72.2%), analphabets (75%), working (77.6%). Studies conducted in Mali and Togo gave comparable results, which give perspectives for a prevention based on education an awareness.

[Conjugal sterility at Dakar CHU: epidemiological profile and evaluation limits apropos of 429 cases]. / Stérilité conjugale au chu de Dakar: profil épidémiologique et limites du bilan a propos de 429 cas.

The writers draw up the outcome of the medical management of infertiles couples at Dakar's teaching hospital over a period of 7 years (1983-1989). Restrictives factors (low rate incomes, social and psychological obstacles) make that médical management difficult. The responsibilities are shared among the couple with sex ratio of 1 man for 3 women. Among the women the etiologies dominated are the sterility of the Phaloppe tubes (81%) among men with the oligo and the azoospermy (32 and 27%). Sterility within married couples is a problem of public health that becomes more acute every day. A better handling of this problem through preventive medicine and elementary sanitary training is necessary.