Stakeholder's perception of the health information system performance in Burkina Faso.

Introduction: the health information system (HIS) in Burkina Faso has improved significantly in recent years. In order to suggest further improvements, we specifically assessed the HIS performance indicators of the epidemic surveillance system from the perspectives of the stakeholders. Methods: we conducted a mixed methods study to assess the performance through timeliness and completeness indicators, strengths, and weaknesses of the HIS in Burkina Faso with specific focus on epidemic surveillance in the health districts of Dandé and Tenkodogo for the period of 2016 to 2019. Results: fewer than 35% of health districts were able to report at least 90% completeness of community reports since 2017. In 2018, four districts did not exceed 1% completeness of community reports. Some concerns remain related to a need of local support and inter-sectoral collaboration. The technical and organizational factors affect process and performance of the system directly or indirectly through behavioral determinants. Conclusion: the ability to measure the performance of all health facilities and to share all community reports online are challenges for the health system in Burkina Faso. New technologies, training-sensitization, and the involvement of actors with influence on social or behavioral change could help to ensure dynamic performance, if perceptions of actors are taken into account.

Information System as part of epidemic management in Burkina Faso: from plan to reality (Field Findings).

BACKGROUND: Health information systems (HIS) in most developing countries face many challenges. In view of the recurrent weaknesses in preparedness and response during the management of epidemics, we have examined the organization and functioning of the health information system in Burkina Faso. METHODS: We conducted a cross-sectional study from January 1, 2020 to March 31, 2020 including a review of HIS documents, key informant interviews and direct observations. The study was conducted at the public primary health care (PHC) and community level of Bama and Soumagou, in the rural health districts of Dandé and Tenkodogo. Study participants included community-based health workers (CBHWs) and health workers in the PHC areas, community-based organization animators (CBOAs), CBO monitoring-evaluation officers and members of the District management team (DMT). RESULTS: While reporting forms used in all health facilities are standardized, they are not necessarily well understood at community level and at the health centers. Reports prepared by CBHWs are often delayed by the head nurse at the primary health care service. Case definitions of epidemic diseases are not always well understood by community-based health workers and front-line health workers. CONCLUSION: The health information system in Burkina Faso can be improved using simple strategies. There is a need to hold regular training/refresher sessions for agents involved in surveillance and to ensure the development of simplified case definitions for emerging diseases and/or diseases of public health interest for community use. Furthermore, existing epidemic management committees need to be revitalized.

Balancing professional autonomy and authority at the margins of a fragile state: Front-line health workers' experiences in Burkina Faso.

The availability of diagnostic equipment, medical products and basic infrastructure is limited in most low-income societies. Poor motivation among health workers as well as recruitment and retention problems are key factors contributing to poor health care services in developing countries. The current paper describes how the front line cope with these difficult working conditions. Data for this study come from anthropological fieldwork in two districts of Burkina Faso and include a total of 27 unstructured and 40 semi-structured interviews with staff at dispensaries and medical centres in the two districts. Analytically, we make a distinction between their professional autonomy and their professional authority. We find that while the health workers experience a certain degree of professional autonomy, in the sense that they rely on their own clinical judgement and their discretion as decision makers and gatekeepers, their professional authority is constantly challenged when working at the margins of the state. Through improvisations and bricolaging, they compensate for the many shortcomings, but many of them feel that their skills are waning and that their professional identity threatened. Thus, massive strengthening of the front-line health worker's capacity is imperative for future improvement of health care services in Burkina Faso.

Comprendre l'influence des facteurs contextuels sur la participation communautaire à la santé : une étude de cas dans le district sanitaire de Tenkodogo, au Burkina Faso.

Le Burkina Faso met en œuvre depuis plusieurs années la stratégie de la participation communautaire. Des comités de gestion (CoGes) ont été mis en place dans les centres de santé de la première ligne et doivent participer aux prises de décisions. L'objectif principal de cette stratégie est de favoriser l'utilisation des services de santé et une adhésion massive des communautés aux activités de promotion de la santé. Seulement, on constate que les résultats escomptés par les autorités sanitaires tardent à se réaliser. Le présent article convoque les facteurs liés au contexte socioculturel du district sanitaire, pour analyser le phénomène de la participation communautaire. L'étude s'est déroulée dans le district sanitaire de Tenkodogo, situé dans la région administrative du Centre-est, à environ 190 km de la capitale. Cette étude exclusivement qualitative, a utilisé deux méthodes de collecte : les entretiens individuels et les focus groups. Les participants à l'étude sont les chefs de ménage ( n = 48), les membres des CoGes ( n = 10), les agents de santé ( n = 8) et les agents de santé communautaire ( n = 24). La méthode de l'analyse de contenu a été utilisée pour l'analyse des données. Les résultats de l'étude montrent que plusieurs facteurs socioculturels influencent la dynamique de la participation communautaire dans le district. Ce sont les conditions économiques, la perception négative des services de santé, les inégalités sociales de sexe et d'âge, le faible ancrage social des organisations communautaires, les rivalités inter-villages et les conflits coutumiers. L'étude relève également que les communautés ne perçoivent pas leur implication dans le processus décisionnel des services de santé comme une priorité. Leurs principales attentes s'orientent vers la disponibilité de soins de qualité et à coût réduit.

"Children get sick all the time": A qualitative study of socio-cultural and health system factors contributing to recurrent child illnesses in rural Burkina Faso.

BACKGROUND: In Burkina Faso, the government has implemented various health sector reforms in order to overcome financial and geographical barriers to citizens' access to primary healthcare throughout the country. Despite these efforts, morbidity and mortality rates among children remain high and the utilization of public healthcare services low. This study explores the relationship between mothers' intentions to use public health services in cases of child sickness, their social strategies and cultural practices to act on these intentions and the actual services provided at the primary health care facilities. Focusing on mothers as the primary caregivers, we follow their pathways from the onset of symptoms through their various attempts of providing treatment for their sick children. The overall objective is to discuss the interconnectedness of various factors, inside and outside of the primary health care services that contribute to the continuing high child morbidity and mortality rates. METHODS: The study is based on ethnographic fieldwork, including in-depth interviews and follow-up interviews with 27 mothers, informal observations of daily-life activities and structured observations of clinical encounters. Data analysis took the form of thematic analysis. RESULTS AND DISCUSSION: Focusing on the mothers' social strategies and cultural practices, three forms of responses/actions have been identified: home-treatment, consultation with a traditional specialist, and consultation at the primary health care services. Due to their accumulated vulnerabilities, mothers shift pragmatically from one treatment to another. However, the sporadic nature of their treatment-seeking hinders them in obtaining long-term solutions and the result is recurrent child illnesses and relapses over long periods of time. The routinization of the clinical encounter at rural dispensaries furthermore fails to address these complexities of children's illnesses. CONCLUSIONS: The analysis of case studies, interviews and observations shows how mothers in a rural area struggle and often fail to receive care at public healthcare facilities. Health service delivery could be organized in a manner that responds better to the needs of these mothers in terms of both access and retention.

Teaching minority children hygiene: investigating hygiene education in kindergartens and homes of ethnic minority children in northern Vietnam.

OBJECTIVES: Ethnic minority children in Vietnam experience high levels of hygiene- and sanitation-related diseases. Improving hygiene for minority children is therefore vital for improving child health. The study objective was to investigate how kindergarten and home environments influence the learning of hygiene of pre-school ethnic minority children in rural Vietnam. DESIGN: Eight months of ethnographic field studies were conducted among four ethnic minority groups living in highland and lowland communities in northern Vietnam. Data included participant observation in four kindergartens and 20 homes of pre-school children, together with 67 semi-structured interviews with caregivers and five kindergarten staff. Thematic analysis was applied and concepts of social learning provided inputs to the analysis. FINDINGS: This study showed that poor living conditions with lack of basic sanitation infrastructures were important barriers for the implementation of safe home child hygiene. Furthermore, the everyday life of highland villages, with parents working away from the households resulted in little daily adult supervision of safe child hygiene practices. While kindergartens were identified as potentially important institutions for improving child hygiene education, essential and well-functioning hygiene infrastructures were lacking. Also, hygiene teaching relied on theoretical and non-practice-based learning styles, which did not facilitate hygiene behaviour change in small children. Minority children were further disadvantaged as teaching was only provided in non-minority language. CONCLUSIONS: Kindergartens can be important institutions for the promotion of safe hygiene practices among children, but they must invest in the maintenance of hygiene and sanitation infrastructures and adopt a strong practice-based teaching approach in daily work and in teacher's education. To support highland minority children in particular, teaching styles must take local living conditions and caregiver structures into account and teach in local languages. Creating stronger links between home and institutional learning environments can be vital to support disadvantaged highland families in improving child health.

Do health systems delay the treatment of poor children? A qualitative study of child deaths in rural Tanzania.

BACKGROUND: Child mortality remains one of the major public-health problems in Tanzania. Delays in receiving and accessing adequate care contribute to these high rates. The literature on public health often focuses on the role of mothers in delaying treatment, suggesting that they contact the health system too late and that they prefer to treat their children at home, a perspective often echoed by health workers. Using the three-delay methodology, this study focus on the third phase of the model, exploring the delays experienced in receiving adequate care when mothers with a sick child contact a health-care facility. The overall objective is to analyse specific structural factors embedded in everyday practices at health facilities in a district in Tanzania which cause delays in the treatment of poor children and to discuss possible changes to institutions and social technologies. METHODS: The study is based on qualitative fieldwork, including in-depth interviews with sixteen mothers who have lost a child, case studies in which patients were followed through the health system, and observations of more than a hundred consultations at all three levels of the health-care system. Data analysis took the form of thematic analysis. RESULTS: Focusing on the third phase of the three-delay model, four main obstacles have been identified: confusions over payment, inadequate referral systems, the inefficient organization of health services and the culture of communication. These impediments strike the poorest segment of the mothers particularly hard. It is argued that these delaying factors function as 'technologies of social exclusion', as they are embedded in the everyday practices of the health facilities in systematic ways. CONCLUSION: The interviews, case studies and observations show that it is especially families with low social and cultural capital that experience delays after having contacted the health-care system. Reductions of the various types of uncertainty concerning payment, improved referral practices and improved communication between health staff and patients would reduce some of the delays within health facilities, which might feedback positively into the other two phases of delay.

Social and cultural aspects of HIV and AIDS in West Africa: a narrative review of qualitative research.

With the increasing focus on the role of social aspects of the HIV epidemic in sub-Saharan Africa, the need for an overview of existing research dealing with such issues has become more urgent. The objective of this article is to provide a thematic overview of existing qualitative research on HIV and AIDS in the West African region and to analyze the main research findings in order to identify possible gaps and recommend new research themes to inform future research-based interventions. The analysis is based on a total of 58 articles published from 2001 to 2009 in English or French identified through a literature search in seven scientific, bibliographical databases. Searches included terms related to qualitative studies combined with various terms related to HIV/AIDS. The results of this narrative review show that there was a geographical concentration on Nigeria, Ghana, Burkina Faso and Côte d'Ivoire and a strong urban bias, with most studies taking place in the capital cities of these countries. The majority of the studies focused on women or women and men; only four articles dealt exclusively with men, of which only two were on men who have sex with men. The main study groups were people living with HIV, young people or female sex workers. Sexual risk-taking and stigmatization were the themes that were most prominently explored in the articles we reviewed. We conclude that research needs to be strengthened in relation to the analysis of experiences with antiretroviral therapy and the non-optimal access to treatment in West Africa. Also, more research is needed on men and their exposure to HIV/AIDS, as well as on the role of concurrent partnership in the spread of HIV.

Perspectives on child diarrhoea management and health service use among ethnic minority caregivers in Vietnam.

BACKGROUND: In Vietnam, primary government health services are now accessible for the whole population including ethnic minority groups (EMGs) living in rural and mountainous areas. However, little is known about EMGs' own perspectives on illness treatment and use of health services. This study investigates treatment seeking strategies for child diarrhoea among ethnic minority caregivers in Northern Vietnam in order to suggest improvements to health services for EMGs and other vulnerable groups. METHODS: The study obtained qualitative data from eight months of field work among four EMGs in lowland and highland villages in the Northern Lao Cai province. Triangulation of methods included in-depth interviews with 43 caregivers of pre-school children (six years and below) who had a case of diarrhoea during the past month, three focus group discussions (FGDs) with men, and two weeks of observations at two Communal Health Stations (CHGs). Data was content-analyzed by ordering data into empirically and theoretically inspired themes and sub-categories assisted by the software NVivo8. RESULTS: This study identified several obstacles for EMG caregivers seeking health services, including: gender roles, long travelling distances for highland villagers, concerns about the indirect costs of treatment and a reluctance to use government health facilities due to feelings of being treated disrespectfully by health staff. However, ethnic minority caregivers all recognized the danger signs of child diarrhoea and actively sought simultaneous treatment in different health care systems and home-based care. Treatments were selected by matching the perceived cause and severity of the disease with the 'compatibility' of different treatments to the child. CONCLUSIONS: In order to improve EMGs' use of government health services it is necessary to improve the communication skills of health staff and to acknowledge both EMGs' explanatory disease models and the significant socio-economic constraints they experience. Broader health promotion programs should address the significant gender roles preventing highland mothers from seeking health services and include family elders and fathers in future health promotion programs. Encouraging existing child health care practices, including continued breastfeeding during illness and the use of home-made rehydration solutions, also present important opportunities for future child health promotion.

Cost of integrated vector control with improved sanitation and road infrastructure coupled with the use of slow-release Bacillus sphaericus granules in a tropical urban setting.

A field test of integrated vector control was conducted in a tropical urban setting with a combination of a floating, slow-release, granular formulation of Bacillus sphaericus and environmental engineering measures (renovation of roads, collective water pumps, and cesspool lids). The targets were Culex quinquefasciatus and Anopheles gambiae in the two biggest towns of Burkina Faso (West Africa). Within the intervention zone, water pumping stations were improved and the surroundings drained to prevent the accumulation of stagnant water. Roads were leveled and given either simple gutters on each side or a concrete channel on one side to drain runoff water. Garbage containers were installed to provide an alternative to the drainage channels for waste disposal. Septic tanks were modified so that they could be emptied without destroying their lid. This study showed that it is possible to implement mosquito control in a tropical urban environment with teams of young people rapidly trained to apply a biological larvicide without any tools other than an iron bar to lift cesspool lids. Environmental improvements were initially costly, but demanded little subsequent expenditure. Local inhabitants' committees were mobilized to provide people with information and monitor the efficacy of the measures. Compared with what people spent individually on mosquito prevention and malaria medicine, these measures were not expensive, but many expected the community to pay for them from existing taxes, e.g., for water treatment and disposal. The necessary funding and logistics require a municipal organization with neighborhood support, if the measures are to be effective.

Hygiene and sanitation among ethnic minorities in Northern Vietnam: does government promotion match community priorities?

Improving sanitation and hygiene to prevent infectious diseases is of high priority in developing countries. This study attempts to gain in-depth understanding of hygiene and sanitation perceptions and practices among four Ethnic Minority Groups (EMGs) in a rural area of northern Vietnam. It is based on extensive participatory observations in 4 villages and 20 case households over a period of six months (May-October 2008). In addition, 10 key informants and 60 household-members were interviewed and 4 focus group discussions conducted. The study found that among the four selected EMGs the cultural perceptions of hygiene and sanitation which inform everyday hygiene practices did not differ substantially and were similar to hygiene explanations found in the rural majority population elsewhere in Vietnam. However, the difficult living conditions, particularly in highland communities, reinforce a sense of marginalization among the EMGs, which had great impact on how they perceive and respond to government sanitation interventions. The enclosed latrines promoted by authorities are met with reluctance by the EMGs due to cultural perceptions of the body as permeable and therefore, vulnerable to 'dirty air' such as bad smells from human faeces. In addition, the prioritization of specific sanitation hardware solutions by the central government aimed at increasing coverage creates expectations and dependency among the EMGs that hygiene 'comes from the outside society', resulting in low levels of community initiated actions. Based on these findings, we suggest that future hygiene promotion strategies aim for a closer match between community priorities and government hygiene policies, e.g. by allowing for a larger diversity of low-cost sanitation solutions. Scaling up participatory community-based hygiene promotion is also recommended to curb dependency and spark initiatives in ethnic minority communities. Finally, interventions should focus on hygiene "software"--promoting hygiene behaviour changes known to effectively prevent hygiene related diseases.

Impact of slow-release Bacillus sphaericus granules on mosquito populations followed in a tropical urban environment.

A floating, slow-release, granular formulation of Bacillus sphaericus (Neide) was used to control mosquito larvae in two suburban areas of two tropical cities: Ouagadougou and Bobo-Dioulasso, Burkina Faso. A circular area of 2 km2, diameter 1,600 m, was treated in each city using a similar, smaller area 1 km away as an untreated control. Mosquito captures were made in houses in four concentric circles, from the periphery to the center; each circle was 50 m in width. Mosquitoes were captured in CDC light traps or from human landings. More than 95% of the mosquitoes were Culex quinquefasciatus (Say) (Diptera: Culicidae). The human landing catches provided twice as many mosquitoes as did the CDC traps/night/house. The treatments resulted in important reductions relative to the control area and to preintervention captures. The reduction was more prominent in the inner circle (up to 90%) than in the outer circle (50-70%), presumably because of the impact of immigrating mosquitoes from nontreated breeding sites around the intervention area. This effect was more pronounced for light trap catches than from human landings. The impact of treatment was also measured as the mean ratio of mosquito density in the two outer circles to that of the two inner circles. This ratio was approximately 1:1 before the intervention and reached 1:0.43 during the intervention. This comparison does not depend on the assumption that, in the absence of intervention, the mosquito population development in the two areas would have been identical, but does depend on the homogeneity of the intervention area. The study showed that it is possible to organize mosquito control in a tropical, urban environment by forming and rapidly training teams of young people to carry out the mosquito control mostly using a biopesticide that can be applied without any tools except an iron bar to lift lids on some cesspits.

Keeping up appearances: perceptions of street food safety in urban Kumasi, Ghana.

The growing street food sector in low-income countries offers easy access to inexpensive food as well as new job opportunities for urban residents. While this development is positive in many ways, it also presents new public health challenges for the urban population. Safe food hygiene is difficult to practice at street level, and outbreaks of diarrheal diseases have been linked to street food. This study investigates local perceptions of food safety among street food vendors and their consumers in Kumasi, Ghana in order to identify the most important aspects to be included in future public health interventions concerning street food safety. This qualitative study includes data from a triangulation of various qualitative methods. Observations at several markets and street food vending sites in Kumasi were performed. Fourteen street food vendors were chosen for in-depth studies, and extensive participant observations and several interviews were carried out with case vendors. In addition, street interviews and Focus Group Discussions were carried out with street food customers. The study found that although vendors and consumers demonstrated basic knowledge of food safety, the criteria did not emphasize basic hygiene practices such as hand washing, cleaning of utensils, washing of raw vegetables, and quality of ingredients. Instead, four main food selection criteria could be identified and were related to (1) aesthetic appearance of food and food stand, (2) appearance of the food vendor, (3) interpersonal trust in the vendor, and (4) consumers often chose to prioritize price and accessibility of food--not putting much stress on food safety. Hence, consumers relied on risk avoidance strategies by assessing neatness, appearance, and trustworthiness of vendor. Vendors were also found to emphasize appearance while vending and to ignore core food safety practices while preparing food. These findings are discussed in this paper using social and anthropological theoretical concepts such as 'purity', 'contamination', 'hygiene puzzles', and 'impression behaviors' from Douglas, Van Der Geest, and Goffman. The findings indicate that educating vendors in safe food handling is evidently insufficient. Future public health interventions within the street food sector should give emphasis to the importance of appearance and neatness when designing communication strategies. Neglected aspects of food safety, such as good hand hygiene and cleanliness of kitchen facilities, should be emphasized. Local vendor networks can be an effective point of entry for future food hygiene promotion initiatives.

The fear of awful smell: risk perceptions among farmers in Vietnam using wastewater and human excreta in agriculture.

Vietnamese farmers' health-risk awareness, knowledge, and practices related to their use of wastewater and human excreta was investigated in an anthropological study by a multidisciplinary team in peri-urban Hanoi and Nghe An Province. Farmers identified health risks associated with their use of excreta and wastewater, but they viewed these as unavoidable risks related to production. They perceived the health risks as different for the use of wastewater and human feces. They perceived health risks from wastewater as non-serious because it remained on the skin and only caused skin problems, but they considered health risks from non-composted smelly feces serious because it entered the body through 'polluted' air. Most farmers were more aware of threats to health from 'dirt' entering the domestic environment than of the health risks during their work. The concept of 'dirt' should be separated from understanding of germs, viruses, and parasites so that it is understood that things that carrying health risks cannot always be identified by their 'dirtiness' or smell. Farmers mainly considered hygiene and health as women's issues. Men's responsibility for the health and hygiene of the family should therefore be emphasized.

Early home-based recognition of anaemia via general danger signs, in young children, in a malaria endemic community in north-east Tanzania.

BACKGROUND: Ethnographic studies from East Africa suggest that cerebral malaria and anaemia are not classified in local knowledge as malaria complications, but as illnesses in their own right. Cerebral malaria 'degedege' has been most researched, in spite of anaemia being a much more frequent complication in infants, and not much is known on how this is interpreted by caretakers. Anaemia is difficult to recognize clinically, even by health workers. METHODS: Ethnographic longitudinal cohort field study for 14 months, with monthly home-visits in families of 63 newborn babies, identified by community census, followed throughout April - November 2003 and during follow-up in April-May 2004. Interviews with care-takers (mostly mothers) and observational studies of infants and social environment were combined with three haemoglobin (Hb) screenings, supplemented with reports from mothers after health facility use. RESULTS: General danger signs, reported by mothers, e.g. infant unable to breast-feed or sit, too weak to be carried on back - besides of more alarming signs such as sleeping all time, loosing consciousness or convulsing - were well associated with actual or evolving moderate to severe anaemia (Hb

Love, lifestyles and the risk of AIDS: the moral worlds of young people in Bobo-Dioulasso, Burkina Faso.

The HIV epidemic has had a profound impact on people's everyday life in most African societies. A large proportion of all new HIV infections involves young people between 15 and 25 years. The objective of this paper is to explore local moral worlds of young people in Bobo-Dioulasso, Burkina Faso, and discuss how the HIVS epidemic affects their reflections on their everyday life and their perceptions of sexual relationships. Based on anthropological fieldwork, including focus-group discussions, in-depth interviews and participant observation, a total of 57 young people between 15 and 25 years were followed over a 3-month period. Using the notion of 'lifestyle', the paper shows how structural factors of unemployment and poverty paired with global discourse on AIDS present the young people with frustrations and quandaries in relation to their hopes and images of love, faithfulness and modern living. The data shows that the HIV epidemic contributes to and accelerates their feeling of living in a risk society and of being at risk. In order to cope with these uncertainties and contingencies, local discourses of trust and fidelity become extremely important and to most young people HIV prevention is synonymous with finding a faithful partner and/or using condoms.

Prevention of mosquito nuisance among urban populations in Burkina Faso.

This paper addresses the problems of mosquito control in urban areas of Burkina Faso. The main objectives are to examine relevant socio-cultural aspects in relation to a mosquito control intervention using a biolarvicide with main emphasis on local perceptions of mosquito nuisance and existing practices of mosquito control, including the cost of protective measures at household level. This is the report of an inter-disciplinary research project carried out in the two major towns of Burkina Faso, Bobo-Dioulasso and Ouagadougou, in 1999 and 2000, respectively. Both quantitative and qualitative methods were used in the ethnographic part of the study. Two questionnaire surveys were conducted in both study areas: one prior to the intervention (n=1083) and the other after the intervention of the treatments with bio-larvicide (n=956). In addition, 70 in-depth interviews and 17 focus group discussions (FGDs) were conducted. The findings show that mosquitoes are considered an important problem in the urban areas, both as a nuisance and a health risk and that the local population is very active in applying mosquito control measures at the household level. The intervention project was received positively by the local population with a decline in the perceived level of annoyance. The causal relationship between mosquitoes and malaria is clear, but the explanatory framework of the relationship between mosquitoes and other diseases is still under debate. The most common prevention methods are mosquito coils and aerosol spray, even though bed nets are perceived to be the most efficient and effective method. The investments in coils and aerosol sprays alone would mean an increase of 40% in the national figures for health expenditure at household level.

Illness transmission and proximity: local theories of causation among the Bissa in Burkina Faso.

Anthropological studies of African conceptions of illness have often worked with a division between the natural and the supernatural, with the focus being on the efficient, or final, causes of an illness. This approach tends to maintain local African explanations of sickness within a framework of exoticism. Based on a study among the Bissa in southeastern Burkina Faso, this paper offers an alternative analysis, with the main focus being on how the process of transmission is conceived. Four different modes of illness transmission are identified: (1) ingestion of improper substances, (2) breaking of social taboos, (3) sorcery, and (4) improper interaction with spirits. Notions of proximity and improper sharing of space play a role in all four types of illness transmission. I demonstrate how local theories of illness transmission indicate a dynamic interaction between spatial domains and social relationships. Such a focus may well be more useful for health planners than the one that emphasizes the differences between African and biomedical notions of causation.

Muted voices: HIV/AIDS and the young people of Burkina Faso and Senegal.

This article explores the discrepancies between the vocal public discourse on HIV/AIDS and sexuality as generally encouraged by policy-makers and donor communities in Africa, and the often hushed voices of their target groups: young people in African communities. Based on fieldwork among urban youth in Senegal and Burkina Faso, we describe the silence of young people with regard to HIV/AIDS and sexuality as a social phenomenon, with focus given to family relations, peer relations and gender aspects in partnerships. Drawing on Foucault and Morrell, an inability and unwillingness to speak about HIV/AIDS and sexuality are analysed as a response to an everyday life characterised by uncertainty. This response represents a certain degree of resistance, while it constitutes a major barrier to any HIV/AIDS prevention effort. Finally, we stress that despite great constraints in their everyday lives, young people have some room to manoeuvre and are able to apply some negotiating strategies to reduce sexually-related health risks.