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The impact of a Computerized Immunization Register (CIR) on Expanded Program on Immunization (EPI), with sending SMS to parents before immunization sessions, has never been studied in sub-Saharan Africa. The objective of this study is to measure EPI quickness and completeness of vaccinations after sending call-back SMS to parents through CIR put in place in a health center. In a health center, chosen at random (Colma 1) in the city of Bobo Dioulasso, Burkina Faso, West Africa, mothers, at first EPI session, if they had a mobile phone available at hand or in her surrounding, were randomized for receiving, or not, a call-back SMS before following EPI sessions, after child registration on a Francophone CIR (Siloxane's Intervax ©). Mothers, which were sent SMS and did not correctly followed sessions were asked through mobile phone why their child was late for EPI. 523 newborns were included in the study, with 253 whose parents were sent SMS, and 268 being informed of sessions only by ordinary methods. At second EPI session at 2 months of age, there was a statistical significant increase of coverage for children whose parents received SMS (p0.001). Quickness to come also to this session was significantly shorter when parents received SMS (p=0.03). At third EPI session at 3 months of age, attendance to EPI for children whose parents were sent SMS was significantly better (p0.001). Quickness to come to this session was shorter for children with SMS (p=0.02). At fourth EPI session at 4 months of age, attendance for children with SMS was significantly better for children whose parents were sent SMS (p0.001). Quickness to come to this session was better but not significantly different (p=0.49). Out of 101 children registered as late for EPI sessions in Colma 1 CIR, even with call-back SMS, 19 (19%) parents could not be reached on the telephone. 31/82 (38%) mothers had shifted for EPI to a more proximate vaccination center (Colma 2), and 5 (6%) to private or civil servants clinic. 14/82 (17%) mothers had been travelling far from health center. Ten (12%) admitted neglect of EPI sessions. Two (2%) children had deceased, and one mother did not come back to Colma 1 after her child's AEFI. One child has been dismissed two times of vaccination following recommendation not to open a measles multi-dose vial for a single child, and did not come back. Of 523 children registered in CIR, 77 (14.7%) could not be found in the paper registers of Colma 1. Quickness and completeness for EPI is increased by sending SMS with help of CIR. An official number should be given for each child registered in CIR, consulted by health staff admitting children in urgency, allowing EPI vaccinations completion. With CIR safeguards, CIR should replace paper registers and should be used to send EPI reports by internet at central levels, helping MOH coverage determination and MAPI surveillance. The fall of coverage due to restriction policy not to open a multidose vial for a single child is low. Health staff should institute telephone call-back for badly immunized children registered on CIR and incorporate in it, with SMS call-back, pregnant women, to better complete prenatal sessions and tetanus vaccination.

This paper intends to analyze the health care system in Lebanon from the organizational and financial points of view. It allows for an understanding of the health services' market by tackling it from different angles: supply versus demand, private versus public sectors, curative versus preventive services, hospital versus ambulatory care. This study necessitated a review of all previous surveys made in this field, during the after-war period. It also needed the daily collection and follow-up of pertinent data with all private and public agencies and concerned ministries, over a one-year period. In addition, a critical analysis has been made to the survey Conditions de vie des ménages, en 1997, that was carried out by the Central Administration of Statistics, that came to complete the missing data concerning household expenditures on insurance and health services. Especially that this survey covered the same period (1997), subject of this study. The paper reveals that, although the private sector is the main provider of both hospital and ambulatory care, private hospitals are flourishing on public money, whereas outpatients care is mainly financed by the households. Evidence shows that the Lebanese health care system succeeded in resolving the problem of accessibility to primary, secondary and tertiary health care, responding thus to the value of equity. But, at the price of an ever escalating cost, threatening the sustainability of the system. This is what is attained in this paper, as it shows clearly that expenditures on health have reached an alarming level of the GDP share. Our purpose being providing solid arguments in favor of reforming the health system.

Social inequalities constitute a major obstacle to the social and economic cohesion of a country, particularly those affecting the health field. In the field of cancer screening, the current situation is that of a social gradient of participation and strong territorial inequalities. This paper reports on the results of two interventional investigations to add incentives to the existing device to provide screening tests for specific populations. A prospective trial with a collective randomization unit was set up from April 2011 to April 2013 in the 3 areas of Northern France (Aisne, Oise and Somme), to assess social workers' help with screening of colorectal cancer (Prado trial). A retrospective study was conducted on the experience of mammobile driving in the area of Orne for several years. The analysis of the results shows that each of these devices is capable of reducing or even erasing social and territorial inequalities at a reasonable cost to society. It also shows that in terms of screening, inequalities can only be reduced if additional devices dedicated to particular populations are added to the national system according to a principle of proportionate universalism.

The precarity of the elderly is a threat that becomes more and more consistent when diseases, disabilities and handicaps become established. Access to care becomes an imperative. The difficulties of implementing palliative and support measures lead to growing precariousness. Their defects have serious consequences for the quality of life of the elderly, and disturb them in the intersubjective and subjective domains, particularly on the most vulnerable person's affects. We analyze in this paper the mechanisms underlying precariousness, and we propose preventive and palliative measures using semiotic analysis.

Based exclusively on drugs approved by provincial public health insurance systems, many authors have reported significant variability in terms of access to anticancer drugs (ACD) among Canadian citizens, raising problems of equal access to these drugs.In this paper, we emphasize that the mere presence on the list of public drug plans cannot be considered to be a sufficient indicator to determine the real availability of anticancer drugs (ACD) for the patient. We describe and compare four sets of regulators defined in each province and determine their effects on the accessibility of ACD for patients in each province. The term regulator comprises the conditions which must be observed for access via the public health insurance system as well as the rules (strategies) decided by the third-party payer for the management of these conditions.The results of our analyses lead to the conclusion that there is indeed a variation between provinces in terms of access to drugs financed by public funds, but that this variability primarily impacts less important treatments.

Free access to medicines is an important element in the implementation of health care access policies. Paradoxically, this aspect is rarely addressed in the literature on this subject. The Ville-Evrard psychiatric hospital introduced so-called "poverty prescriptions" allowing free drug dispensing, independently of specific PASS (Permanent Access to Health_ Care) systems. This paper presents the results of a study of all poverty prescriptions issued by the facility in 2011./t provides an analytical description of this system and shows that, despite the absence of strict controls, it was used relatively rarely.

This paper describes a knowledge transfer experiment that has been conducted since September 2012 in Argenteuil (Val d'Oise, France). This experiment is part of an interventional research project called DeCL/C: "Knowledge translation on social and spatial inequalities: a tool to raise local awareness and mobilization to lessen cancer screening participation rate disparities': The project is carried out by health geographers from Paris Ouest University (UPO) and the National Association of Cities for Public Health (Elus, Sante Publique et Territoires, ESPT). It encompasses two main components: intervention designed to implement a knowledge co-production and transfer process among researchers, stakeholders and decision makers at various levels. This knowledge concerns social and spatial determinants of inequalities of access to breast cancer screening programmes in cities. The research is multidisciplinary (geography, sociology, political science, epistemology) and is designed to measure the impact of this knowledge co-production and transfer in terms of actions in the targeted cities (six cities in the Paris region) as well as the reduction of inequalities of access to breast cancer screening programmes. This article, based on knowledge transfer literature and an empirical experiment in Argenteuil, describes the ongoing knowledge transfer process. It also highlights Argenteuil stakeholders' and decision makers' interest in action and research. The analysis of the knowledge co-production, sharing and ownership process by local actors a e both "strategic" and "profound'

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.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.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.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.

Proton beam therapy is indicated as a treatment for some rare tumours and paediatric tumours because the technique allows a good local control with minimal toxicity; the growing number of centres that use proton beam therapy is associated with an increase of dosimetric and clinical data for other malignant tumours as well. This paper reviews potential indications of proton beam therapy. A systematic review on Medline was performed with the following keywords proton beam therapy, cancer, heavy particle, charged particle. No phase III trial has been published using proton beam therapy in comparison with the best photon therapy, but numerous retrospective and dosimetric studies have revealed an advantage of proton beam therapy compared to photons, above all in tumours next to parallel organs at risk (thoracic and abdominal tumours). This could be accompanied with a better safety profile and/or a better tumoural control; numerous phase 0, I, II, III and IV studies are ongoing to examine these hypotheses in more common cancers. Use of proton beam therapy is growing for common cancers within clinical trials but some indications could be applied sooner since in silico analysis showed major advantages with this technique.

Social inequalities in health remain a major problem in France despite recent efforts to improve access to prevention and care. In France, the reduction of inequalities involves many actors, including the Instances régionales d'education et de promotion de la santé (IREPS, the Regional Authorities for Health Education and Promotion). This paper focuses on health education for deaf and hard of hearing youth. The educational team responsible for providing health education among this population has highlighted the dangers of internet use among deaf and hard of hearing youth. The overall objective is to "promote the critical and responsible use of the Internet", focusing in particular on social and technical skills. The project is a long-term intervention based on the active involvement of the educational team and the participating youth. Another objective of the project is to enable participants to contribute to online resources. This has involved using QR codes to create digital resources. The study found high levels of satisfaction among all the participants. These findings provide further evidence of the importance of providing health education to deaf and hard of hearing people.

Primary care medicine is first in line to meet the necessary changes in our health care system. Innovations in this field pursue three types of objectives: accessibility, quality and continuity of care. The Department of ambulatory care and community medicine of the University of Lausanne (Policlinique médicale universitaire) is committed to this path, emphasizing interprofessional collaboration. The doctor, nurse and medical assistant coordinate their activities to contribute efficiently to meet the needs of patients today and tomorrow. This paper also addresses how our department, as a public and academic institution, might play a major role as a health care network actor. A master degree dissertation in health management has started to identify the critical success factors and the strategic core competencies needed to achieve this development.

Deafness concerns about 7% of the French population. In this context, the clinic of obstetrics and gynecology of Grenoble teaching hospital established two adaptation actions in the pregnant signing-deaf patient's management: a partnership with French Sign Language interpreters from the deaf patient reception and care unit, and sign language training for nine professionals. The aim of this study is to evaluate this patient management and to propose some potential improvements.This descriptive study is made through information from both numeric and paper files of 22 deaf pregnant patients.A significant adaptation of patient management during scheduled consultations and hospitalisation in the clinic is observed, whereas adaptation rate is weak for emergency situations.The patient management adaptation turns out to be perfectible, through the anticipation of the entire pregnancy consultation schedule. In emergency situations, the creation of a sign language interpreter on-call duty would greatly improve the health care access of these patients.

Primary care medicine is first in line to meet the necessary changes in our health care system. Innovations in this field pursue three types of objectives: accessibility, quality and continuity of care. The Department of ambulatory care and community medicine of the University of Lausanne (Policlinique médicale universitaire) is committed to this path, emphasizing interprofessional collaboration. The doctor, nurse and medical assistant coordinate their activities to contribute efficiently to meet the needs of patients today and tomorrow. This paper also addresses how our department, as a public and academic institution, might play a major role as a health care network actor. A master degree dissertation in health management has started to identify the critical success factors and the strategic core competencies needed to achieve this development.

The rapid development of new health technologies for which there is limited, but promising, evidence has resulted in a daunting challenge — to provide care that meets population health needs and optimizes patient outcomes, demonstrates an efficient use of healthcare resources, and upholds basic principles of equity, access, and choice. In this paper, we introduce ‘Access with Evidence Development’ as a possible mechanism for addressing this challenge and discuss its application to the “Zamboni procedure” for Multiple Sclerosis.

Since 1996, the Democratic Republic of Congo (DRC) has been the theatre of armed conflict. More than 5.4 millions have died and 500,000 to 1,000,000 women have been raped. As a result of permanent insecurity including frequent massacres, burning of villages and plundering of personal property and crops, millions of Congolese people especially in eastern regions have been displaced with around 1.3 million in internal refugee camps. Rural populations have abandoned farming that was the main source of employment, food, and income. The purpose of this paper is to describe the socioeconomic impact of this armed conflict particularly on the health of women and children. Consequences include i) decreased food production, ii) worsening food insecurity and malnutrition, iii) reduced household income, and iv) inadequate health care leading to epidemic outbreaks of diseases such as cholera, measles, and meningitis. Food insecurity and poverty affect around 70% of the population. Chronic malnutrition and growth retardation affect 38% of children. The mortality rate for children under 5 has reached 205 per 1000 live births. Other than achieving lasting peace that is a prerequisite for development in the DRC, the main priority must be to provide victims with multiform assistance aimed at restarting the economy and ensuring food self-sufficiency, thereby reducing both malnutrition and child mortality. Better access to healthcare and to psychosocial, medical, and legal services is also needed for rape victims.

With the advent of cost-recovery system in the 1990s in Burkina Faso, patients contribute to the financing of health centres (CSPS), which are managed by management committees (COGES). Asking patients to pay, however, erects a financial barrier to treatment for the poorest. The aim of this paper is to study how the financial resources from cost recovery can be used to improve equity of access to health care. The study took place in the health district of Ouargaye and documents the financial position of 17 COGES over a period of 12 months, with their accounting data. The results show that COGES spent an average of 7 million francs CFA, 65% for the purchase of medicines, 15% for operating costs, 7% for staff salaries and bonuses to COGES and 3.4% for discounts for health workers. Average revenue per COGES was 7.3 million FCFA. The sale of generic drugs accounted for 82% of revenue and fees for medical care to 10%. The average profit was 300,000 FCFA. The cost recovery rate averaged 104% and the profit margin on the sale of drugs 31%. Discounts to health workers represented 30% of the revenues from medical fees. The average cash position of a COGES was 3.1 million FCFA. The financial standing of the COGES is thus good. They could improve access to care and provide the standards discount to employees (20%) by removing fees for services, reducing the margins on the sale of drugs, or by using a portion of profits to exempt the poorest from payment.

Mental Health is a Public Health issue, however, access to relevant treatment often does not meet the population needs. Patients, their relatives, as well as Mental Health professionals are still victims of a high stigmatization process. Whatever the countries and the cultural settings, public beliefs and attitudes towards mental illness (insanity) and mentally ills (insane people) play a major role in the ranking of priorities given to Mental Health national prevention and care policies. This paper presents the methodology of the research-action entitled "Mental Health in General Population: images and realities (MHGP)" carried out by the World Health Organisation Collaborative Centre (Lille, France) and the Direction of research, studies, assessment and statistics (Drees) of the French Ministry of Health, in a sample of 36 000 French subjects over 18 years old, between 1999 and 2003.The MHGP Survey is an international multisite study aimed at: Describing, in the general population, the representations attached to insanity, mental illness and depression, and the related care; Assessing the prevalence of major psychiatric disorders in the general population; Rising awareness about Mental Health issues among various social groups: social workers, local elected, care professionals, by including them in the research-action procedure; Promoting the development of Community Psychiatry, following WHO main Guidelines.About 900 individuals were recruited in 47 centres in metropolitan France between 1999 and 2003 according to the following criteria: i) informed consent to take part in the study, ii) age over 18 yrs, iii) not residing in a care institution and not homeless. Subjects were selected by quota sampling stratified by age, gender, educational and occupational level with the general population of the general population of the centre as sampling frame. The quotas were defined on the basis of the 1999 national population census. The data was collected by 1700 nursing students using a 50-item structured questionnaire administered in face-to-face interviews; mean length 40 minutes. The interviewers received a special 3-day training course. The assessment included a specially developed questionnaire enabling description of representations of insane, mentally ill and depressed individuals; the Mini International Neuro-psychiatric Interview (Sheehan and Lecrubier); a specific questionnaire on care consumption in case of positive MINI diagnosis and a sociodemographic questionnaire. In each centre, a team of supervisors (psychiatric staff) coordinated the interviews and the data collection; the local elected and the social and care networks were given information about the research and the results. The results of the local study were systematically presented to the general population, the local elected and the social and care professionals. Prevalence rates of mental disorders are very similar to those observed in other studies. Results on social representations and public beliefs in general population can compare with the international data available. MHGP research-action remains the first study of this scale on the topic of Mental Health in France, combining representations and prevalences description. It allowed the development of anti-stigma actions at a national and local level.

Although economic evaluation of health networks is part of the legal obligations that have to be met since March 2007, its contours still have to be defined. The purpose of this paper is to present the reasons for and approaches to such an economic analysis. Lessons will also be drawn from two economic evaluations carried out in other areas than health networks (respectively, task delegation between health care professionals and the assessment of added value for health care technologies).

This paper analyses the main results and prospects concerning research and studies about social inequalities in health in France. Research orientations, which may contribute usefully to defining health and social policies in this field and favour their development are then proposed. Health policy content and implementation placing high priority on the problem of social inequalities in health are discussed.

BACKGROUND: Over the last decade, the increasing number of people experiencing difficult social conditions--especially in urban areas--has led to the implementation of free (health and social care) clinics for uninsured and/or poor people. METHODS: In this paper, we give some results of multidisciplinary (sociological and epidemiological) research conducted among patients attending five of these free clinics in the Paris area. RESULTS: The statistical and qualitative analyses revealed the diversity of the studied population, as well as the conditions in which these consultants attended such clinics, what kind of services and help they used and, furthermore, what kind of social ties were strengthened. CONCLUSION: These results lead us to discuss our present knowledge of the determinants of the utilization of the healthcare system, not only among vulnerable people, but perhaps also amongst the general population.

The main goal of the Canada Health Act is to guarantee that Canadian residents have reasonable access to a comprehensive and universal health care plan. However, reduced federal funding for health care and increases in health care costs due to technical and scientific developments have created unprecedented financial pressures on provincial health care systems. The right to health care, once perceived as one of the pillars of Canadian society, may be imperiled. This article will provide a detailed analysis of the nature and scope of the right to health care from mainly a legal, but also from a political, perspective. Based on the premises that the Canada Health Act is basically a financial agreement between the Federal and provincial governments and that it does not enshrine a substantive right on which individuals may claim services, the author explores the nature and scope of this right under Québec legislation. Indeed, the Québec Health and Social Services Act has, since the 1960s, included various provisions that establish a right of access to health care services. This right, however, is fraught with regulatory, organizational and financial limits. The first part of this paper examines relevant regulation from an historical perspective, highlighting the relationships between federal and Québec provincial legislation. In the second part, the author explores exhaustively the principal provisions relevant to the right to health care. This entails the analysis of administrative regulations as well as of the responsibilities of the various provincial, regional, institutional and professional authorities involved. Ultimately, as this study will demonstrate, the availability of health care services depends more on a vague process than on a legal right to health care. This conclusion is further confirmed by the analysis of the adjudication process of patient complaints provided under the Québec Health and Social Services Act and by the limited case law on the right of access to services. Even though judges are generally favorable to patients claims, court interventions remain ad hoc and a posteriori. But if the right of access to health care seems limited, its scope is nonetheless important. The right to health care acts as an obstacle to the current dismantling of health care services and to government withdrawal from this field. It also places limits on abusive, arbitrary and discriminatory decision-making and obliges public authorities to take into closer consideration patients' rights in formulating its health care policy and budgets. This protective role of the right to health care is currently illustrated by the politicians' insistence that the ongoing health care reform is not affecting the quality or quantity of available services.

Several studies have shown that a substantial part of teenagers suffer from light to severe health problems but that many of them feel embarrassed to consult or have difficulties in accessing to proper health care. This situation is linked with two main factors: On one hand, adolescents live a transitional period of their life during which they no longer depend on their parents to decide when and where to consult and do not know how to use the health care system. On the other hand, as they are struggling for their autonomy, they usually want to solve their problems themselves and any form of help may be felt as a menace to their growing independence. This paper discusses several opportunities to solve the problem of the discrepancy between teenagers' health needs and health care. One first avenue is to improve the health professionals' knowledge and skills and to encourage a physician-patient relationship based on empathy, confidentiality and mutual confidence, as well as the professional's ability to focus not only on problems but also on the adolescent's resources. A second mean is to enhance the accessibility and attractiveness of the health care facilities and services. A third way is to develop a network approach, a close collaboration with the professionals who work closely with young people and who can thus encourage them to seek help when needed (low-threshold approach).

Cathi Albertyn's paper, an edited and updated version of her presentation at "Putting Third First," argues that both human rights and the law can play an important, if limited, role within a wider set of national and international strategies to reduce women's vulnerability to HIV. It analyzes the nature of women's vulnerability to HIV/AIDS, and highlights some of the issues and lessons in using rights and the law to advance gender equality and reduce women's vulnerability to HIV/AIDS.

In the absence of a cure for AIDS, attention has turned to the possibility of developing a preventive vaccine for HIV infection. Yet many scientific, ethical, legal, and economic obstacles remain. At the current rate, the development and production of an effective vaccine could take 15 to 20 years or longer. If tens of millions more HIV infections and deaths are to be avoided in the coming decades, vaccine research needs to be greatly expedited. Furthermore, it must be undertaken ethically, and the products of this research must benefit people in developing countries. This article, an edited and updated version of a paper presented at "Putting Third First," addresses challenges arising in HIV preventive vaccine research in developing countries. It does not address clinical research in developing countries relating to treatments or therapeutic vaccines. Nor does it address legal and ethical issues relating to HIV vaccine research in industrialized countries, although similar issues arise in both contexts. The article concludes that while ethical codes are silent on the obligation to undertake research and development, international law provides strong legal obligations--particularly with regard to industrialized states--that should be invoked to accelerate HIV vaccine development, and distribution.

Using contextual factors beyond individual factors, contextual analysis allows a more accurate identification of at-risk populations, which could be useful when planning health programs. Multilevel models, widely used in British and North-American social epidemiology research but less frequently in France, are particularly suitable to analyse contextual data, because they take into account their hierarchical structure. This paper addresses methodological issues in the utilization of multilevel models, and reports some results which illustrate their potentials compared to those of more conventional statistical methods. As well as other methods, multilevel models are able to take into account the hierarchical structure of the data when estimating parameters. Furthermore, and more specifically, these models can also be viewed as useful tools to investigate contextual effects. Their particular interest is to disentangle individual-level variability and between-group variability. Comparing the group-level variance before and after introduction of individual-level characteristics allows to assess the extent to which between-group variability is linked to compositional effects. Multilevel models can also help examine whether the between-group variations affect all the members of the groups, or only specific sub-groups. Finally, they can estimate how much of this complex between-group variability is explained by the contextual factors included in the model. The overall conclusion is that multilevel statistical methods should be used in social epidemiology studies dealing with individual and contextual data, to produce results that are both richer and more consistent.

The female condom was developed in the 1980s. It is a contraceptive device used by women that protects against both pregnancy and sexually-transmitted diseases (STDs) including HIV infection. Two studies have investigated the contraceptive effectiveness of the female condom, and it was found to be as effective as other barrier methods. It has been shown to be effective against STD and HIV transmission in vitro but there is only limited evidence of its efficacy in vivo. No serious local side effects or allergies have been reported and the female condom can be used with any type of lubricant, spermicidal cream or foam. The female condom is the only device other than the male condom that has been shown to prevent HIV transmission. The female condom has been marketed in 13 countries since the summer of 1996. Most of these countries are industrialized and the selling price in these countries is too high for developing countries. Sub-Saharan Africa has very high prevalence rates for HIV infection, at least 30% of the general population in Eastern and Central regions. The epidemic is also spreading fast in some parts of the Western region. In Ivory Coast for example, 12 to 15% of pregnant women are infected. African women are subordinate to men in many aspects of their lives, politically, educationally, socially and sexually. This sexual inequality makes them highly vulnerable to STDs, including HIV, and unwanted pregnancies. This paper reviews 10 of the 15 studies carried out in sub-Saharan African countries between 1990 and 1996 and compiled by the World Health Organization. Recruitment methods, education of subjects, methodology and assessment of acceptability differed between studies. Despite these limitations, most studies concluded that the women who participated in the trials generally found the female condom acceptable. Acceptability was established quicker among prostitutes than among other women and men found the female condom less acceptable than did women. However, the sample size is too small to draw any firm conclusions. Commercial sex workers in the studies reviewed were very interested in this new method because it gave them an additional method of safer protection during sex. However, they were occasionally faced with difficult negotiations with some clients, refusal to use the female condom and sexual violence. Reuse of the device was reported in four studies, but the term reuse is seldom defined. In cases where it was defined, the frequency of reuse, with washing of the device, accounted for no more than 1% of the total number of uses. The acceptability of the female condom among women other than prostitutes faces two obstacles, the reaction of the woman's regular partner and attitudes to the device itself (appearance, difficulties or uneasiness concerning its use). However, some women liked it because it provided dual protection against pregnancy and STDs and sexual pleasure. The moderate level of acceptability to male partners may be overestimated because women whose partners disliked the device would be more likely to discontinue its use. The studies of acceptability reviewed here show that use of the female condom in Africa is realistic and that it provides women with more independent protection. Initial negative perceptions of the device are often replaced with a more positive reaction after several uses. The experience gained with use reduces the technical problems. We need to overcome the stereotypes, simplifications and strong opinions that threaten to damage the acceptance of this new method and efforts to encourage women to adopt it. However, we still require further clinical data on the effectiveness of the female condom at preventing pregnancy and HIV transmission. Availability of the female condom is improving in Africa. Pilot marketing studies were launched in 1996 in Guinea, Zambia, South Africa, followed by Uganda and Tanzania. There are local initiatives in Ivory Coast and Zimbabwe. (ABSTRACT TRUNCThis work discusses the female condom and the context of women's lives in sub-Saharan Africa, analyzes results of studies on acceptability conducted in Africa, and assesses the prospects for future use of the method in Africa. Studies have been conducted throughout the world on the efficacy, tolerance, and acceptability of the female condom. The two studies of contraceptive effectiveness, carried out in England, the US, and Latin America, showed it to be about as effective as other barrier methods. Both studies had high dropout rates. The female condom has been demonstrated to be effective in vitro against transmission of HIV and sexually transmitted diseases, but evidence of efficacy in vivo remains limited. The high prevalence of HIV infection in eastern and central Africa and its rapid spread in parts of western Africa, and the growing desire of African women to space or limit births, indicate a need for protection that could be met by the female condom. The subordinate position of African women at all levels limits their ability to negotiate on sexual topics, including contraception. 10 of the 15 studies of acceptability of the female condom, carried out in 9 sub-Saharan African countries between 1990 and 1996 and compiled by the World Health Organization, were reviewed. The studies were limited by small sample size, selective recruiting, lack of consistency in methods and analysis, and a tendency to ignore dropout rates and motives. Despite the limitations, the studies found female condoms to be acceptable to certain groups of women, especially prostitutes. Acceptability was established more rapidly among prostitutes, although large proportions reported the method to be unacceptable to some of their clients. Results of acceptability studies were more variable among non-prostitutes. Acceptability among men has been insufficiently documented. Stereotypes and oversimplifications must not be allowed to hamper promotion of the female condom. It is recommended that further study of the contraceptive and disease prevention efficacy of the female condom be conducted and that availability and accessibility of the method be increased for African women.