This study took place in the health zone of Comè, Bopa, Grand-Popo, and Houéyogbé. It covers an area of 1120 km² and is located in the department of Mono [8] .

This was a cross-sectional survey, conducted among beneficiary households in the health zone of Comè, Bopa, Grand-Popo, and Houéyogbé.

The primary target of the study was community health workers, and the secondary target was households. The performance of health workers was measured based on information provided by households.

The probabilistic method with the cluster random sampling technique was used. The clusters were thus the 4 municipalities of the health zone. The sample size was calculated using the Schwartz formula adjusted with the cluster effect k: $n=k{Z}_{\alpha }^{^2}\frac{pq}{i^{^2}}$where n is the sample size, p is the theoretical percentage of good

performance among CHWs (p = 50%), q is the theoretical percentage of poor performance, $Z_{\alpha }^2$ is the Z score for the confidence level (95%) (here $Z_{\alpha }^2$ = 1.96), k is the cluster effect (k = 1.5) and i the margin of error (i = 5%) [9] . This calculation made it possible to estimate a minimum size, giving 636 households (578 with a 10% increase) or 160 households per municipality.

Each CHW in the health zone is responsible for a defined catchment area covering approximately 4 households. Thus, the 640 households surveyed corresponded to the catchment areas of 160 CHWs, who were all systematically included in the study.

We worked on 640 people, composed of 65.6% women and 34.4% men. The sex ratio female/male was therefore 1.9. The most represented age groups were those of [25 to 40[ years with 45.9% and [40 to 60[ years with 42.8%. In terms of education, 29.7% of respondents have no level of education, while 44.4% have a primary level and 21.9% a secondary level. In terms of religion, the population is mainly Christian (47.7%) and animist (46.7%), reflecting the cultural and spiritual diversity of the area. The vast majority of respondents (76.4%) live in common-law unions, while 31.9% are traders and 25% are artisans. Analysis of disease-related outcomes among children under 5 years of age over the past two weeks revealed that 91.7% of households reported that no child under 5 years of age had suffered from diarrhea, while 6.6% reported one case and 1.7% reported two cases. Regarding fever, 87.2% of households did not observe any cases, but 10.6% reported a sick child and 2.2% reported at least two children affected. For cough, 87.5% of households observed no cases, while 9.7% reported a sick child and 2.8% reported at least two cases ( Table 1 ).

Access to drinking water remains a major challenge as 31.6% of households obtained their water from wells, some of which were unprotected (23.6%). In addition, 33.3% used a borehole and 30.9% a pump, but 78.9% did not have water available directly at home, forcing them to travel long distances. Only 19.1% of households treated their water before consumption, and the majority used Aquatabs tablets (69.7%). Three out of 10 households did not have latrines (29.4%), which still leads to open defecation (14.4%). Among those with latrines, 53.8% were considered dirty. Handwashing facilities were absent in 87.2% of households. The study also shows that 91.9% of households did not have a bin, and 22.2% threw their waste in the open air ( Table 2 ).

Almost all (95.5%) households were able to recognize their community relay, and 89.5% reported having received a visit from them in the last three months.

The topics covered during the visits mainly included:

1) Water, hygiene, and sanitation (85.2%).

2) Malaria and LLINs (68.9%).

3) Childhood vaccination (46.9%).

The CHW action appeared effective in promoting good practices, with educational sessions reaching a large number of households (78.3% participated).

The main hygiene awareness topics were: Environmental sanitation (89.7% of households); Drinking water consumption (80.5%); Use of latrines (72.9%); Hand washing facilities (69.3%) ( Table 3 ).

The choice of CHW was considered “good” by 62.3% of households; “acceptable” by 35.2% of households and “bad” by 2.5%. Furthermore, the services offered were considered good by 56.7%, acceptable by 40.9%, and bad by 2.3% ( Figure 1 ). However, 72.2% of respondents did not make any suggestions for improvement. The main recommendations concerned the provision of material and financial resources (12.8%), the improvement of the living and working conditions of CHWs (1.3%), and the strengthening of care for children under 5 years old (4.1%) ( Table 3 ).

The community health workers (CHW) were predominantly male (71.3%) and aged 25 to 45 years (80%). Most of the CHWs had a secondary education (71.3%) and lived in a common-law relationship (78.1%). In addition, 85% had received training on the activity package ( Table 4 , part A).

Of the 160 CHWs, 43.1% had poor performance; 50.6% had acceptable performance; and 6.3% had good performance. Furthermore, regarding the factors associated with the performance of community health workers, no significant association was revealed with sex, age, level of education, or marital status. However, trained CHWs were 2.5 times more likely to have good performance than untrained ones (OR = 2.5; 95% CI: [1.1 - 7.0]; p = 0.03) ( Table 4 , part B).

The high proportion of households aware of the CHWs (95.5%) and having received their visit (89.5%) demonstrates their active engagement in the community. These results are consistent with those of the study by Watson et al., which highlighted that community interventions increase the adoption of good hygiene practices and reduce the prevalence of diarrheal diseases in low-and middle-income countries [11] . Furthermore, a study by Fewtrell et al. showed that awareness programs conducted by community agents contribute to a significant reduction in health risks related to contaminated water [12] .

Only 19.1% of households treat their water before consumption, a proportion lower than the WHO recommendations, which advocate widespread adoption of household water treatment methods to reduce diarrheal diseases [6] . This is probably due to the low level of education among individuals in this context. A study conducted in several developing countries shows that the use of Aquatabs tablets and water filters can significantly improve the quality of drinking water and reduce cases of diarrhea by 30 to 50% [13] . However, the adoption of these practices is often limited by lack of awareness and the costs associated with water treatment products. Although we hypothesized that education level influences water treatment practices, this relationship was not formally tested in our analysis and should be considered a limitation of the study.

The lack of latrines in 29.4% of households and the practice of open defecation (14.4%) remain major problems in the study area because the lack of sanitation infrastructure contributes to the transmission of waterborne diseases and increases child morbidity [14] . A study conducted by Clasen et al. (2015) demonstrated that the installation of latrines reduces the prevalence of diarrheal diseases in children under five by 27% [15] . Furthermore, the low presence of handwashing facilities (87.2% of households) is a major concern, knowing that handwashing with soap can reduce enteric infections by 40% [16] [17] .

Analysis of data on the prevalence of diarrheal diseases in children under five years of age shows a relatively low prevalence (6.6% of households report a case). This reduced prevalence could be explained by the impact of awareness raising and CHW interventions. These results are similar to those reported by Cha et al., who found that community-based water, hygiene, and sanitation interventions reduced the incidence of diarrheal diseases by 20% - 50% depending on the context [18] .

The household satisfaction assessment shows that the CHW services are generally considered acceptable. However, suggestions for improvement mainly concern the insufficient material and financial resources allocated to the CHW (12.8%), a problem also identified by a study conducted in Uganda, which showed that the lack of resources limits the effectiveness of community initiatives [19] .

The fact that households mainly requested additional material and financial resources highlights the need for program managers and policymakers to strengthen logistical support and provide incentives for CHWs. Without adequate resources, their capacity to promote hygiene and sanitation remains limited, which could compromise the sustainability of community health interventions.

In addition, the study assessed the performance of community health workers based on intervention, satisfaction, and perceived quality criteria. It emerged that less than 10% of the CHWs had a performance deemed “good,” while 43.1% had poor performance. This finding highlights the need to strengthen the skills of these actors. Analysis of factors associated with the performance of the CHWs showed that training on the activity package is the only statistically significant element (p = 0.03), doubling the chances of obtaining good performance (OR = 2.5). These results corroborate those of previous studies demonstrating the positive impact of continuous training on the effectiveness of community interventions [6] [20] . It therefore appears essential to invest more in capacity building to improve the results of the CHWs on the ground.

In summary, this study demonstrates that community health workers are well integrated into their communities and contribute positively to improving hygiene and sanitation practices. However, their overall performance remains limited, with training emerging as the only factor significantly associated with better outcomes. Strengthening capacity building and logistical support, therefore, appears essential to optimize the contribution of CHWs to public health in Benin.