'We had to be there, Present to Help Him': Local Evidence on the Feeling of Safety in End-of-Life Care in Togo.

Objectives: For patients with diabetes and cancer at the end-of-life and their families, the safety sought in end-of-life care leads them to opt for home care. In developing countries where palliative care is not yet effectively integrated into public health policies, factors such as long distances to hospital referrals, lack of adequate infrastructure and shortage of specialised health professionals create a sense of insecurity for people seeking end-of-life care. The present study explored the factors that reinforce the feeling of security and insecurity of family members who have opted to accompany their relatives with diabetes and/or advanced cancer at the end-of-life at home in Togo. Materials and Methods: This was an ethnographic approach based on observations and in-depth semi-structured interviews with people with the following characteristics: family members (bereaved or not) with experience of caring for a patient with diabetes and cancer at home at the end-of-life. The data were analysed using content and thematic analysis. This was done to identify categories and subcategories using the qualitative analysis software Nvivo12. Results: The results show that of the ten relatives interviewed, eight had lived with the patient. Factors contributing to the feeling of security in the accompaniment of end-of-life care at home by the family members were, among others: 'Informal support from health-care professionals,' 'social support' from relatives and finally, attitudes and predispositions of the family members (presence and availability to the patient, predisposition to respect the patient's wishes at the place of end-of-life care and predisposition to talk about death with the dying person). Conclusion: The 'informal support of health-care professionals', the 'perception of the home as a safe space for end-of-life care' and the 'social support' of family members contributed most to the feeling of safety among family members accompanying their diabetic and cancer patient family members at the end-of-life at home in Togo. Therefore, palliative and end-of-life care must be rethought in public health policies in Togo to orientate this care toward the home while providing families/caregivers with the knowledge and tools necessary to strengthen care.

Prevalence, associated factors and level of dependence of substance use among urban secondary school students, Benin.

The use of psychoactive substances is constantly increasing, particularly among young people. This study aimed to estimate the prevalence, associated factors and the level of dependence of those substances among secondary school students in Benin. This cross-sectional study included 627 students in grades 8-12, selected using a multi-stage sampling technique. Data were collected using the ASSIST questionnaire, followed by urine screening. Logistic regression analysis was performed to estimate factors associated with substance use. Overall, the lifetime prevalence of psychoactive substance use was 95.4% (95% CI = 93.4-96.9), while the current use was 78.8% (95% CI = 75.3-81.9). The most commonly used substances in the past 3 months were alcohol, followed by stimulants and tobacco; 221 samples were analysed. Twenty-two (9.95%) were positive by urine screening. Substances detected were tramadol, fentanyl, THC, K2, BZDs, alcohol, methamphetamine and cotinine. Of the current users, 2.27% (n = 11) were at high risk of dependency. An association was found between substance use and age (p = 0.02). In conclusion, this study came up with a high prevalence of substance use among students. There is a need to develop and implement a health education programme in secondary schools to raise awareness of the potential risks.

Nonmedical use of tramadol among secondary school students in Benin, Africa.

Background: Nonmedical use of tramadol among the young Beninese population is an increasing public health concern. However, there is little research on tramadol use in West Africa.Objectives: This study aimed to assess the prevalence, factors associated with nonmedical use of tramadol and to determine the level of therapeutic intervention needed.Methods: A cross-sectional study design and multi-stage sampling method was used among 384 secondary school students, within the age group of 10-24 years old who gave their consent/assent. An interviewer-administered modified questionnaire based on ASSIST was administered. Urinary toxicological test was performed using NarcoCheck® quick for qualitative detection of tramadol or its metabolites. Logistic regression analysis was performed to identify factors associated with nonmedical use of tramadol.Results: The average age of our respondents was 17 ± 2 SD years old; 58.3% were males and 41.7% females. The lifetime prevalence of nonmedical use of tramadol was 9.6% (95% CI: 6.7-12.6) (13.4% males and 4.4% females) and the average age at onset was 14.8 ± 1.8 years old. Only 1.4% (n = 4) were using tramadol as shown by urine screen. Among users, 45.9% reported a hazardous level of use and required a brief intervention. In a multivariate logistic regression model, tobacco (P < .001), cannabis (p = .023) and amphetamine (p = .037) were significantly associated with nonmedical use of tramadol. The most prevalent motives for nonmedical use of tramadol was experimentation (45.9%) and the leading source for obtaining tramadol was street-level markets (86.5%).Conclusion: These results indicate that nonmedical use of tramadol affects young in Benin and represent a considerable concern among secondary school students.

Overview and factors associated with pregnancies and abortions occurring in sex workers in Benin.

BACKGROUND: Behavioural and structural factors related to sex work, place female sex workers (FSWs) at high risk of maternal mortality and morbidity (MMM), with a large portion due to unintended pregnancies and abortions. In the African context where MMM is the highest in the world, understanding the frequency and determinants of pregnancy and abortion among FSWs is important in order to meet their sexual and reproductive health needs. METHODS: Data from two Beninese cross-sectional surveys among FSWs aged 18+ (2013, N = 450; 2016, N = 504) were merged. We first performed exploratory univariate analyses to identify factors associated with pregnancy and abortion (p < 0.20) using Generalized Estimating Equations with Poisson regression and robust variance. Multivariate analyses first included all variables identified in the univariate models and backward selection (p ≤ 0.05) was used to generate the final models. RESULTS: Median age was 39 years (N = 866). The proportion of FSWs reporting at least one pregnancy during sex work practice was 16.4%, of whom 42.3% had more than one. Most pregnancies ended with an abortion (67.6%). In multivariate analyses, younger age, longer duration in sex work, previous HIV testing, having a boyfriend and not using condoms with him were significantly (p < 0.05) associated with more pregnancies. CONCLUSION: One FSW out of five had at least one pregnancy during her sex work practice. Most of those pregnancies, regardless of their origin, ended with an abortion. Improving access to various forms of contraception and safe abortion is the key to reducing unintended pregnancies and consequently, MMM among FSWs in Benin.

Structural determinants of health: a qualitative study on female sex workers in Benin.

The objective of this paper is to expose those socio-structural contexts revealing the social injustice and human rights violations that sub-Saharan women face every day when forced into sex work by unemployment or sickness. Results of a qualitative study highlighting some key structural determinants of sex work and HIV infection among FSWs will be presented and examined through the lens of the WHO conceptual framework for action on the social determinants of health. The results showed that most FSWs had lacked the necessary financial support at some point in their lives. Also, both the socioeconomic and political context failed to provide proper support to prevent involvement in sex work and the consequent risks of HIV. The cultural and societal values placed on the health and well-being of FSWs in Benin appear to depend on the degree to which sexual violence and adultery are perceived as a collective social concern. This portrait of FSWs calls for both long-term interventions through a structural determinant approach to HIV prevention, targeting all the women who could face such a financial situation well before their entry into sex work, while maintaining short and medium-term interventions on the intermediary determinants.

Social accountability in primary health care in West and Central Africa: exploring the role of health facility committees.

BACKGROUND: Social accountability has been emphasised as an important strategy to increase the quality, equity, and responsiveness of health services. In many countries, health facility committees (HFCs) provide the accountability interface between health providers and citizens or users of health services. This article explores the social accountability practices facilitated by HFCs in Benin, Guinea and the Democratic Republic of Congo. METHODS: The paper is based on a cross-case comparison of 11 HFCs across the three countries. The HFCs were purposefully selected based on the (past) presence of community participation support programs. The cases were derived from qualitative research involving document analysis as well as interviews and focus group discussions with health workers, citizens, committee members, and local authorities. RESULTS: Most HFCs facilitate social accountability by engaging with health providers in person or through meetings to discuss service failures, leading to changes in the quality of services, such as improved health worker presence, the availability of night shifts, the display of drug prices and replacement of poorly functioning health workers. Social accountability practices are however often individualised and not systematic, and their success depends on HFC leadership and synergy with other community structures. The absence of remuneration for HFC members does not seem to affect HFC engagement in social accountability. CONCLUSIONS: Most HFCs in this study offer a social accountability forum, but the informal and non-systematic character and limited community consultation leave opportunities for the exclusion of voices of marginalised groups. More inclusive, coherent and authoritative social accountability practices can be developed by making explicit the mandate of HFC in the planning, monitoring, and supervision of health services; providing instruments for organising local accountability processes; strengthening opportunities for community input and feedback; and strengthening links to formal administrative accountability mechanisms in the health system.

Outreach strategies for the promotion of HIV testing and care: closing the gap between health services and female sex workers in Benin.

BACKGROUND: Regular voluntary counseling and testing is a key component of the fight against HIV/AIDS. In Benin, the project SIDA-1/2/3 established to decrease HIV/sexually transmitted infection (STIs) among female sex workers (FSWs), implemented a multifaceted intervention, including outreach activities. The objective of this article was to present potential advantages and limitations of 3 categories of outreach interventions designed to increase the use of testing services among FSWs in Benin. METHODS: This analysis is based on ethnographic fieldwork conducted in Benin from June to December 2012. RESULTS: Sixty-six FSWs and 24 health care workers were interviewed. Their narratives revealed 3 main factors impeding the development of appropriate HIV testing behavior. These negative elements can be positioned along a continuum of health care behaviors, with each stage of this continuum presenting its own challenges: fear or lack of motivation to use testing services, inaccessibility of care when the decision to go has been made, and a perceived lack of quality in the care offered at the health care center. Many of these needs seem to be addressed in the outreach strategies tested. However, the study also exposed some potential barriers or limitations to the success of these strategies when applied in this specific context, due to social disruption, mobility, access to care, and hard to reach population. CONCLUSIONS: To increase the use of testing services, an outreach strategy based on community workers or peer educators, along with improved access to testing services, would be well adapted to this context and appreciated by both FSWs and health care workers.

Violence, condom breakage, and HIV infection among female sex workers in Benin, West Africa.

OBJECTIVE: To examine the relationship between violence, condom breakage, and HIV prevalence among female sex workers (FSWs). METHODS: Data were obtained from the 2012 cross-sectional integrated biological and behavioral survey conducted in Benin. Multivariable log-binomial regression was used to estimate the adjusted prevalence ratios of HIV infection and condom breakage in relation to violence toward FSWs. A score was created to examine the relationship between the number of violence types reported and HIV infection. RESULTS: Among the 981 women who provided a blood sample, HIV prevalence was 20.4%. During the last month, 17.2%, 13.5%, and 33.5% of them had experienced physical, sexual, and psychological violence, respectively. In addition, 15.9% reported at least 1 condom breakage during the previous week. There was a significant association between all types of violence and HIV prevalence. The adjusted prevalence ratios of HIV were 1.45 (95% confidence interval [95% CI], 1.05-2.00), 1.42 (95% CI, 1.02-1.98), and 1.41 (95% CI, 1.08-1.41) among those who had ever experienced physical, sexual, and psychological violence, respectively. HIV prevalence increased with the violence score (P = 0.002, test for trend), and physical and sexual violence were independently associated with condom breakage (P = 0.010 and P = 0.003, respectively). CONCLUSIONS: The results show that violence is associated with a higher HIV prevalence among FSWs and that condom breakage is a potential mediator for this association. Longitudinal studies designed to analyze this relationship and specific interventions integrated to current HIV prevention strategies are needed to reduce the burden of violence among FSWs.