[Community-based approaches in the fight against Buruli ulcer : review of the literature]. / Approches communautaires dans la lutte contre l'ulcère de Buruli : revue de la littérature.

Buruli ulcer (BU) is an infectious skin disease caused by Mycobacterium ulcerans. It mainly affects poor communities living close to bodies of water. In the absence of early treatment, this "neglected" disease can cause lasting deformities and may require limb amputation. It is reported in 34 countries and is the third most common mycobacterial disease in immunocompetent patients. Considerable progress has been made in treatment and prevention. The Cotonou Declaration (2009) describes the recommended control strategies. Although effective, current control strategies are limited because they do not take into account all the factors that influence emergence, prevention and cure of the disease. The control of Buruli ulcer mainly depends on intervention on social, cultural and psychosocial factors that influence preventive and self-care behaviour. The health promotion approach requires collaboration with populations in order to perform simultaneous actions on BU factors in the community setting. Although effective on many health problems, health promotion is not applied in the fight against BU due to the absence of action on all factors such as poverty. This article presents a review of the literature on BU strategies and community approaches. 407 relevant articles published in 1998-2013 period were examined. Eleven programmes are based on a top-down approach, which does not include populations in decision-making processes, unlike the bottom-up participatory approaches recommended in health promotion. Three health promotion programmes and 6 community-based participatory approaches were identified and examined. Community participation and empowerment constitute the basis for a community approach in the fight against Buruli ulcer.

[Health promotion and community-based approach to Buruli ulcer: results of a psychosocial- and behavioural survey in two villages in Benin]. / Promotion de la santé et approche communautaire de l'ulcère de Buruli: résultats d'une enquête psychosociocomportementale dans deux villages du Bénin.

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.

Voluntary HIV testing and risky sexual behaviours among health care workers: a survey in rural and urban Burkina Faso.

BACKGROUND: Voluntary counselling and testing (VCT) together with a safe sexual behaviour is an important preventive strategy in the control of HIV. Although Health care workers (HCWs) are critical in the response to HIV, little is known about VCT and high risk behaviours (HRB) among this group in West Africa. This study aims to assess the prevalence of VCT and HRB among HCWs in Burkina Faso. METHODS: We collected data through a questionnaire in urban areas (Ouagadougou and Bobo-Dioulasso) and rural areas (Poni and Yatenga) among HCWs from 97 health care facilities. Urine samples were collected, screened for HIV using a Calypte(®) test kit and confirmed by Western Blot. Multiple logistic regression analysis was performed to identify factors associated with the use of VCT services and with high-risk sex behaviour. RESULTS: About 92.5% of eligible HCWs participated (1570 out of 1697). Overall, 38.2% of them (34.6% of women and 42.6% of men) had ever used VCT services. About 40% of HCWs reported that fear of knowing the test result was the main reason for not doing the HIV test. Male HCWs (p = 0.001), laboratory workers (p < 0.001), those having two years or more experience (p = 0.03), and those who had multiple partners (p = 0.001) were more likely to have tested for HIV. One fifth of HCWs reported multiple partners. Of these, thirteen percent did not use condoms. HCWs who had multiple partners were significantly more likely to be men, single, living in rural areas, and under the age of 29 years. CONCLUSION: VCT was still very low among HCWs in Burkina Faso, while HRB was high.These findings suggest that 'HCW-friendly' VCT centres should be implemented, securing confidentiality among colleagues. In addition, refreshment courses on HIV risk reduction, counselling and testing are certainly required during the professional career of HCWs.

Non-adherence in adolescent transplant recipients: the role of uncertainty in health care providers.

To optimize self-management and adherence in adolescent patients, HCPs need to discuss not only medical and treatment-related issues, but also general health and psychosocial concerns. Our study aimed to explore how the members of the paediatric team in our programme understand NA in adolescents, and how they define their own role regarding self-management education. We used a sequential mixed methods design and conducted a qualitative observational and in-depth interview study (n=22) and a quantitative descriptive study through self-administered questionnaires (n=31). Our results show a discrepancy between the HCPs' understanding of the complex psychosocial factors impacting on long-term adherence, and their current limited practice of patient education. A number of uncertainties were found to explain the HCPs' perceived difficulty to engage in comprehensive patient education activities: uncertainty regarding (i) the health status of transplant recipients; (ii) a shared operational definition of adherence and the cause of organ rejection in some cases; (iii) the extent to which adherence is a shared responsibility which involves the HCPs as patient educators; (iv) the long-term impact of a LRD. To avoid the risk of conveying incongruent messages, multidisciplinary health care teams need to explicitly acknowledge and discuss the various areas of uncertainty, some of which are inherent to transplantation.

Reconsidering patient empowerment in chronic illness: a critique of models of self-efficacy and bodily control.

Studies that focus on patient empowerment tend to address more specifically two issues of patients' experience of illness: managing regimens and relating to health-care providers. Other aspects of illness experience, such as coming to terms with disrupted identities, tend to be overlooked. The outcome of empowerment is therefore usually referred to as achieving self-efficacy, mastery and control. We conducted an inductive exploratory study, based on individual in-depth interviews with 40 chronically ill patients in Belgium and Italy, in order to understand the process of empowerment as it may occur in patients whose experience of illness has at some point induced a feeling of powerlessness, which we conceptualised as a threat to their senses of security and identity. Our findings show that empowerment and control are not one and the same thing. We describe patient empowerment as a process of personal transformation which occurs through a double process of (i) "holding on" to previous self-representations and roles and learning to control the disease and treatment, so as to differentiate one's self from illness on the one hand, and on the other hand (ii) "letting go", by accepting to relinquish control, so as to integrate illness and illness-driven boundaries as being part of a reconciled self. Whereas the process of separating identities ("holding on") was indeed found to be linked to efforts aimed at taking control and maintaining or regaining a sense of mastery, the process of reconciling identities ("letting go") was found to be linked to a need for coherence, which included a search for meaning and the acceptance that not everything is controllable. We argue that the process of relinquishing control is as central to empowerment as is the process of gaining control. As a "successful" process of empowerment occurs when patients come to terms with their threatened security and identity, not only with their treatment, it may be facilitated by health-care providers through the use of narratives.

[Fever and malaria in children under 5 years of age in Benin: do we have accurate statistics?]. / Fièvres et paludisme chez les enfants de 0 à 5 ans au Bénin: avons-nous de vraies statistiques?

INTRODUCTION: In Benin, mothers generally seek health care for their children with fever and malaria only when complications appear, including severe anemia, convulsions, and coma. Statistics from the national health system are based on consultations at national health care centers and do not take into account existing cases in the community. OBJECTIVES: To determine the prevalence of malaria from the analysis of subjects with fever and their management in two participating villages. This evaluation--and a better approach to fighting childhood malaria--rely on habits of management and care-seeking and the extent of parental participation. METHODS: Parents in two villages were interviewed about their practices in managing fever in children and about active malaria screening. RESULTS: The prevalence of (thick smear-positive) malaria was the same in both villages (p>0.05). Parents brought children to health centers for consultation in only 6% of the cases of fever. Treatment was administered immediately within 48 hours for most children (75%) but only 15% received adequate anti-malarial treatment. DISCUSSION: Care-seeking is highly associated with perceptions and representations of childhood fever: for every case treated at the health centre, 16 remain in the community. CONCLUSION: Adequate management of fever and the malaria often associated with it requires understanding the perceptions and representations of parents, which will make it possible to learn the true proportion of malaria in fevers in the two villages and thus to apply appropriate strategies.

[Perceptions of parental participation by health professionals in childhood malaria control in Benin]. / Perceptions de la participation des parents par les professionnels de santé a la lutte contre le paludisme de l'enfant au Bénin.

The aim of this study was to explore and document the perceptions of health professionals regarding parental participation in the fight against child malaria, specifically with regard to fever management, in Benin (West Africa). The findings indicate that community participation in Malaria control in general, and in the case of children in particular, is essential due to the contributing factors surrounding the disease. This form of participation is different from the one recommended and practiced within the structure of the National Health system. Deep-seated, thorough reform of health care program planning is necessary in order to contribute to the improvement of the population's participation in this process. The concept of health promotion was used to frame and shed light on the analysis of the proposed recommendations. Parents' participation, one that integrates their perceptions and depictions of child fever, is not currently a reality in Benin; the study revealed that the participants seek out and request the development of skills necessary that could enable them to better contribute to the fight against malaria.

Patient empowerment in theory and practice: polysemy or cacophony?

OBJECTIVE: This paper examines how the term "empowerment" has been used in relation to the care and education of patients with chronic conditions over the past decade. METHODS: Fifty-five articles were analysed, using a qualitative method of thematic analysis. RESULTS: Empowerment is more often defined according to some of its anticipated outcomes rather than to its very nature. However, because they do not respect the principle of self-determination, most anticipated outcomes and most evaluation criteria are not specific to empowerment. Concerning the process of empowerment, our analysis shows that (i) the educational objectives of an empowerment-based approach are not disease-specific, but concern the reinforcement or development of general psychosocial skills instead; (ii) empowering methods of education are necessarily patient-centred and based on experiential learning; and (iii) the provider-patient relationship needs to be continuous and self-involving on both sides. CONCLUSION: Our analysis did not allow for the unfolding of a well-articulated theory on patient empowerment but revealed a number of guiding principles and values. PRACTICE IMPLICATIONS: The goals and outcomes of patient empowerment should neither be predefined by the health-care professionals, nor restricted to some disease and treatment-related outcomes, but should be discussed and negotiated with every patient, according to his/her own particular situation and life priorities.

The perspective of patients on their experience of powerlessness.

Although self-determination is a key issue in empowerment, the perspective of patients on their experience of empowerment has been poorly investigated. The authors have attempted to understand better what the process of empowerment means to patients by investigating the situations and feelings of powerlessness from which a process of empowerment might evolve. They conducted 40 interviews of patients with various chronic conditions and looked for the commonalities in their experiences of powerlessness. Their findings show that powerlessness extends well beyond strictly medical and treatment-related issues, as the study participants all expressed or demonstrated to have at some point or another experienced a distressing feeling of insecurity and a threat to their social and personal identities. The authors therefore suggest that an empowering provider-patient interaction should address these issues by providing for reassurance and opportunities for self-exploration as a prerequisite to participation and self-determination in treatment-related decisions.

[Childhood fever in a zone of malaria prevalence in Benin: qualitative analysis of factors linked to seeking care]. / Fièvre chez l'enfant en zone d'endémie palustre au Bénin: analyse qualitative des facteurs associés au recours aux soins.

In Benin, mothers usually go to health facilities when childhood malaria is already in its late stage (severe anaemia, convulsions, unconsciousness). This study was undertaken in a rural area of Benin through a community-based participation action-research aiming to control child malaria with a focus on parental participation. The aim of this research was to better understand the situation with regards to parents' perceptions and perspectives of childhood fever, care seeking behaviour and practices as well as factors that influence the choice of treatment among the various options. The parents were interviewed individually and in focus groups. Care seeking behaviour is strongly influenced by perceptions and personal opinions of childhood fever, which is considered as commonplace and not warranting care in a health centre. Severe malaria cases are perceived as a manifestation of the "bad eyes" and health facilities are consulted only as a last resort. Adequate child malaria control programmes must involve parents in order to take into account their perceptions of the implications of childhood fever.

Health promotion needs of children and adolescents in hospitals: a review.

The concept of health promotion for children and adolescents in hospitals is relatively new, and an international working group within the WHO-network of Health Promoting Hospitals, is currently seeking to establish specific guidelines. An exploratory study based on a literature review was performed in order to identify (i) what are the health promotion needs of children and adolescents when they access the hospital either as patients, as visitors, or as members of their community; and (ii) if there are any recommended strategies to empower children and strengthen their life-skills and participation capacity in the hospital, as recommended by the Ottawa Charter for Health Promotion. The results of this literature review are mainly descriptive of current practices and recommendations regarding organizational issues, health-care providers' practice behavior, health-care providers' skills and training, children's education, education of parents and social environment.

From patient compliance to empowerment and consumer's choice: evolution or regression? An overview of patient education in French speaking European countries.

OBJECTIVE: This paper presents a historical overview of patient education in French speaking (parts of) countries of Europe, as well as the emergence of new concepts in Health care and education. Further it describes the results of research and studies on current practice and political decisions and positions about patient education, based upon laws and regulations. The present trends will be discussed, and propose an overview of the next possible developmental steps. METHODS: Articles, reports and policy documents about publications on patient education in French speaking (parts of) countries of Europe. RESULTS: In the last years, in France, Belgium, Switzerland, Luxemburg, patient education has undergone a lot of changes whether in theories, models, policies or practice. These changes came with the emergence of concepts such as effectiveness of care, chronic disease follow-up, compliance, adherence, health promotion, empowerment, salutogenesis, resilience, patients' rights, health care costs control, coaching, disease management, consumer choice, and participation. Each of these concepts seems to have been defined and implemented in various ways, according to settings or countries. Political and social choices seem to have oriented choices from humanistic approaches to pragmatic decisions, with ethical problems rising. Consensus on definitions are often hard to reach, especially among policy makers, health care teams, health managers, and patient organizations, even though these concepts do coexist in daily practice, sometimes in very conflictual ways. CONCLUSIONS: Hard or subtle, changes are happening in patient education and cannot be ignored. PRACTICE IMPLICATION: Many questions rise on the future of patient education, wondering how to anticipate next models of health care practice, and their ethical and social stakes. Clear positions need to be taken.

Adolescent mothers' perspectives regarding their own psychosocial and health needs: a qualitative exploratory study in Belgium.

OBJECTIVES: We looked at early pregnancy and parenthood as an opportunity to broaden our understanding of the reproductive health education needs met by adolescent girls. METHODS: We conducted an in-depth interview study with 12 adolescent mothers. RESULTS: To become a mother at a young age was perceived as meaningful to all the participants. The participants expressed a need to be addressed as adult parents, who want the best for their child. A variety of psychosocial and health needs emerged over a time span ranging from starting to be sexually active to after the child was born. Social isolation was found to be an important factor of vulnerability. CONCLUSION: The health needs of adolescent mothers extend well beyond counselling around the decision to continue or terminate pregnancy, and subsequent information on contraception methods to avoid further pregnancies. Adolescent mothers need to be supported in their transition to parenthood, and special care should be provided to girls who are socially isolated. PRACTICE IMPLICATIONS: We identified several avenues for health education and counselling to adolescent mothers, from primary prevention to reduce incidence of early pregnancies to tertiary prevention to reduce negative health outcomes for both mother and child.

Child malaria in sub-saharan Africa: effective control and prevention require a health promotion approach.

Malaria remains a vital concern of child survival in sub-Saharan Africa despite the existence of effective curative and preventive measures. It is known that child malaria is underpinned by factors such as socioeconomic, cultural, environmental, and so forth, that must be considered simultaneously in order to effectively control it. This study applied to a rural community in Benin (West Africa) the Health Promotion concept (community participation and empowerment, contextualism, intersectorality, multistrategy, equity, and sustainability) to develop a program in order to control child malaria and close the gap of unsuccessful programs. The study design was a quasi-experimental pre-post conducted over a period of 27 months. As results, 80% of the community members participated in six of the seven sub-projects planned. The prevalence of fever (malaria) was significantly reduced after the intervention (p = 0.008). The recourse to adequate health care has significantly increased after the intervention (chi2 = 48.07, p = 0.000000). All these contributed to a statistically significant reduction of children deaths due to malaria (p = 0.001) in the village. Health Promotion strategies are likely to contribute to sustainable malaria programs' implementation that reduce malaria incidence and deaths in children under five.