Changes in healthcare workers' knowledge about tuberculosis following a tuberculosis training programme.

BACKGROUND: In resource-limited countries, health policy makers and practitioners need to know whether healthcare workers have sufficient knowledge of tuberculosis and its management. OBJECTIVES: We conducted a study to: (1) measure knowledge changes among healthcare workers who participated in a tuberculosis training programme; and (2) make recommendations about future tuberculosis training for healthcare workers in the KwaZulu-Natal Department of Health. METHODS: A cross-sectional study conducted in 2007 measured changes in tuberculosis knowledge of doctors, nurses and other healthcare workers after a training programme based on World Health Organization tuberculosis training modules. Data were collected before and after training using a self-administered, 98-item questionnaire covering eight components. RESULTS: A total of 267 healthcare workers, mean age 40.7 years, answered both pre- and post-training questionnaires. Mean total knowledge scores were low despite significant changes (p<0.001) from a pre-training score of 59.5% to a post-training score of 66.5%. Nurses showed significant improvements in mean total knowledge scores (p<0.001) but had the lowest mean total knowledge score post-training, 63.2%. Doctors had significantly better pre-training (p<0.001) and post-training (p<0.001) mean total knowledge scores compared to nurses. CONCLUSIONS: Improvement in healthcare workers' overall knowledge of tuberculosis during a training programme was not clinically significant. Periodic field training and supervision should be considered to ensure tuberculosis knowledge improvements.

Meeting the challenges of the Ottawa Charter: comparing South African responses to AIDS and tobacco control.

The paper compares the response of the South African Government to HIV and AIDS with the government's policy development concerning the use of tobacco. The high burden of disease from HIV and AIDS in South Africa and the morbidity and mortality from the use of tobacco are outlined. Using the framework of the Ottawa Charter for Health Promotion, the paper reviews and critiques the Government's different stance to building public policy, creating supportive environments, engaging community participation, developing personal skills and re-orienting the health services, for HIV/AIDS and tobacco. The result of these policy choices is described. The lack of adequate implementation of the key elements of the Ottawa Charter has resulted in high morbidity and mortality due to the spread of HIV infection in South Africa. This has also influenced the resurgence of tuberculosis, and the accompanying MDR and XDR TB epidemics. The high prevalence of HIV infection has also meant that the health system is unable to cope with the large numbers of patients requiring anti-retroviral treatment, and the early morbidity and mortality of young economically active people has had devastating social consequences, resulting in the large numbers of orphans. In contrast, South Africa is a signatory to the World Health Organizations' Framework Convention on Tobacco Control, and has successfully implemented many of the policies.

Risky sexual behaviours of high-school pupils in an era of HIV and AIDS.

OBJECTIVE: To identify risky sexual behaviours and demographic factors that place high-school pupils at risk of HIV and AIDS. METHODS: A cross-sectional study was undertaken to explore factors influencing the sexual behaviour of high-school pupils (mean age 15.4 years; SD 1.11). Structured self-reported questionnaires were completed by all grade 10 pupils (N = 805) at all the Wentworth, Durban, public high schools. RESULTS: Significant gender differences in sexual practices were reported, such as males being more likely to engage in sexual activity than females (OR 4.92; p < 0.001). More males (24.8%) initiated sex before age 12, compared with more females (30%) who initiated sex between 16 to 20 years of age (p < 0.001). Significantly more males preferred older partners than females (p = 0.002), more females were forced to have sex than males (p = 0.009), and more males used alcohol on the last occasion of sex than females (p = 0.04). Religious affiliation and parental supervision were found to have a significant effect on sexual activity among pupils. CONCLUSIONS: High-school pupils are at high risk of HIV and AIDS, yet they continue to engage in risky sexual behaviours. Preventive efforts therefore need to be aggressively up-scaled and redirected towards specific risky practices, taking gender differences into account. Contextual factors such as religious norms and parental supervision also require greater attention. Risky sexual behaviours are reflective of a broader crisis in society.

Sex differences in under and over nutrition among school-going Black teenagers in South Africa: an uneven nutrition trajectory.

OBJECTIVES: To investigate the nutritional status of Black South African teenagers by sex and compare it with nutritional profiles of teenagers from other countries. METHODS: The first South African Youth Risk Behaviour Survey (2002) was adapted to include anthropometric data and this paper reports on the prevalence of under and over nutrition among 5322 Black teenagers, aged 13.0-17.9 years, grades 8-11. Prevalence of over nutrition in this study was compared with other countries using a World Bank country economic classification. RESULTS: Significant sex differences were observed for under and over nutrition. Boys (18.4%) had a higher prevalence of underweight than girls (2.6%) (P < 0.005), who were more at risk of overweight than boys (20.9%vs. 4.2%) (P < 0.005). Boys (21.9%) were more stunted than girls (9.4%) (P < 0.05), but stunted girls were at greater risk of overweight than boys across all levels of stunting. The prevalence of overweight among boys (4.2%) was lower than in other countries while for girls (20.9%) was similar to several upper middle and high income countries. CONCLUSION: Gender sensitive strategies are required to address both under and over nutrition among South African teenagers to reduce stunting and future chronic disease epidemics in adulthood. This paper suggests that Black South African teenagers are experiencing an uneven nutritional transition across sex, from under nutrition to over nutrition.

Reasons for inconsistent condom use by rural South African high school students.

AIM: To describe the condom use practices of high school students, compare the beliefs of students who used condoms with those who did not, investigate gender differences in condom use and identify factors that prevent condom use. METHOD: Cross sectional descriptive study of sexually active grade 10 students at 28 rural high schools who completed a self-reporting structured questionnaire. RESULTS: Of n = 353 students, mean age 17.50 y (SD 1.40), n = 249 (70.5%) males and n = 104 (29.5%) females (p < 0.005), n = 136 (38.5%) had used a condom at last sex. Students who used condoms differed from non-condom users in their beliefs that use of condoms did not imply lack of trust (p = 0.03), supported girls' requesting that their partners use condoms (p = 0.002), perceived greater social support (p < 0.005), and had more self-efficacy (p < 0.005). In the model, condom use at last sex was significantly associated with males (p = 0.03), age at first sex (p = 0.02), knowing a person infected with HIV/AIDS (p = 0.03), and condom use self-efficacy (p = 0.001). CONCLUSION: The low rate of condom use amongst these students during the AIDS epidemic is influenced by students' condom use self-efficacy, emphasizing the need for skills' training. The increasing mortality due to HIV/AIDS may be a cue that encourages condom use.

TB in health care workers in KwaZulu-Natal, South Africa.

SETTING: Eight public sector hospitals in Ethekwini municipality, KwaZulu-Natal, South Africa. OBJECTIVE: To describe the incidence of TB, clinical presentation and treatment outcomes among health care workers (HCWs) in public sector hospitals in Ethekwini Municipality, KwaZulu-Natal. METHODS: A descriptive study using a retrospective record review for the period January 1999 to June 2004 was conducted from July 2004 to February 2005. RESULTS: Five hundred and eighty three HCWs were diagnosed with TB. The mean incidence of TB among HCWs for the study period was 1133.0 per 100000 HCWs (standard deviation 282.8). The incidence of TB was highest in the age group 25-29 years and among paramedical staff (registered health professionals other than doctors and nurses). Clinical presentation of TB in HCWs included pulmonary TB 76.5% (n = 322) and MDR-TB 3% (n = 13). Cure was achieved in 22.2% (n = 118) of HCWs, and 40.7% (n = 212) of HCWs completed their treatment. CONCLUSION: The incidence of TB in HCWs in KwaZulu-Natal is alarmingly high, and the high incidence in the younger age groups and the poor treatment outcomes are cause for concern.

Colloquium report: improving the health of school age children in an era of HIV/AIDS in Durban, South Africa.

Increased morbidity and mortality due to the HIV/AIDS epidemic in South Africa necessitates the examination of policies for the protection and support of school age children. At a colloquium held in Durban participants from government and non-government health and education sectors briefed delegates on key policies and programmes for promoting the health and mental health of school age children. Researchers gave evaluative accounts of the impacts of these measures and presented an overview of South African children's health and mental health needs. In the discussions that followed four critical issues emerged: intersectoral collaboration, accountability, retraining middle management, and a more comprehensive strategy to support pupils and teachers infected and affected by HIV/AIDS.

Investigating the mental abilities of rural Zulu primary school children in South Africa.

INTRODUCTION: Maximising the full potential of health and educational interventions in South African schools requires assessment of the current level of mental abilities of the school children as measured by cognitive and scholastic tests and the identification of any barriers to improved performance. OBJECTIVES: This study reports on the application and interpretation of a selected battery of mental ability tests among Zulu school children and the methodological and analytical issues that need to be addressed. DESIGN: The test scores of 806 primary school children from a rural community are presented, based on four tests: Raven's Coloured Progressive Matrices (CPM), an Auditory Verbal Learning Test (AVLT), the Symbol Digit Modalities Test (SDMT) and Young's Group Mathematics Test (GMT). RESULTS: Significant gender differences were found in the test scores, and the mean scores of Zulu children in this study were lower than those reported in other studies. The results of this selected test battery provide data for the further development of appropriate test instruments for South African conditions. CONCLUSION: These results can contribute towards the development of a test battery for South African children that can be used to assess and improve their school performance.

Young people, HIV/AIDS/STIs and sexuality in South Africa: the gap between awareness and behaviour.

AIM: To determine the baseline data of secondary school students in the Midlands district of Kwa-Zulu, Natal, South Africa. The data provide details of students' knowledge about sexually transmitted infections (STIs) including HIV and AIDS, spread, prevention, how they can protect themselves from contracting an STI, their general awareness and sources of information, their perceptions of their vulnerability and their sexual practices. METHODS: A cross-sectional study was carried out among 1113 grade 11 students in 19 randomly allocated secondary schools. Data were collected through structured questionnaires and analysed using the SPSS software package. RESULTS: The results confirm that knowledge levels were high for causes and spread of STIs and the participants were well informed about issues relating to protection against STIs and seeking treatment. However, there was significant deviation in reported behaviours. CONCLUSION: This discrepancy between awareness and behaviour calls for a reorientation of sexuality education to include those elements critical for behavioural change, such as addressing gender discrepancies and promoting skills for communication through planned intervention programmes.

Understanding high school students' risk behaviors to help reduce the HIV/AIDS epidemic in KwaZulu-Natal, South Africa.

Of 901 rural learners (X age 16.1, SD = 2.4) at 10 randomly selected high schools in KwaZulu-Natal, South Africa, those living with a parent were less likely to drink alcohol (P < 0.0001) or use drugs (P = 0.006). Thirty percent (95% CI 26.9, 33.1) were sexually active, and 53.1% used a condom in the past 30 days. The odds of males being sexually active was 7.27 the likelihood of females (95% CI 5.2, 10.1). Only one-third of male respondents always used condoms. Of sexually active respondents, 46.5% had experienced coercive sex. More males (14.1%) than females (3.6%) smoked cigarettes (P < 0.0001). The odds of males drinking alcohol was 4.5 times that of females (P < 0.0001). Smoking, (OR 2.42, 95% CI 1.32, 4.44) and drinking, (OR 2.67, 95% CI 1.71, 4.19) among learners increased the likelihood of sexual activity. With youth at increasing risk of HIV/AIDS in KwaZulu-Natal, South Africa, interventions to reduce learners' risk behaviors are required.

An epidemiological perspective of substance use among high school pupils in rural KwaZulu-Natal.

OBJECTIVES: To investigate prevalence and the factors influencing substance use among rural high school pupils in KwaZulu-Natal in order to develop and implement intervention programmes. DESIGN: Cross-sectional study. SETTING: Twenty-eight high schools in southern KwaZulu-Natal. SUBJECTS: One thousand three hundred and eighteen grade 10 pupils. OUTCOME MEASURES: An anonymous self-reporting questionnaire was used to investigate the use of alcohol, tobacco (cigarettes), cannabis and solvents. RESULTS: Of the male scholars, 52.9% (95% confidence interval (CI): 45.4-60.3) reported ever using alcohol, 16.9% (CI: 11.5-24.0) reported using cannabis, and 13.1% (CI: 7.2-22.5) had smoked more than one cigarette daily. Among male pupils 45.5% (CI: 38.6-52.6) had inhaled benzine and 34.6% (CI: 28.0-41.8), thinners; 7.4% (CI: 3.4-15.2) had used cocaine and 4.1% (CI: 1.0-10.6), crack. Female pupils reported significantly less use of alcohol (25.5%, CI: 17.6-35.3), cannabis (2.3%, CI: 1.3-4.1), cigarettes (more than one daily) (2.0%, CI: 1.0-4.1), and inhalation of benzine (18.8%, CI: 13.8-25.2) and thinners (10.8%, CI: 7.2-16). Logistical regression indicated that the odds of smoking cigarettes increased significantly (p < 0.0005) with use of the other substances. CONCLUSION: The results of this study confirm the prevalence of multi-substance use among pupils at the majority of rural high schools in this district and the need for targeted interventions to reduce/prevent this.

Implications of the prevalence of stunting, overweight and obesity amongst South African primary school children: a possible nutritional transition?

OBJECTIVE: To investigate the relationship between stunting and levels of overweight/obesity among South African school children, using two definitions of overweight and obesity, based on the WHO and International Obesity Task Force (IOTF) criteria. DESIGN: Cross-sectional descriptive analysis of the nutritional status of primary school children, using primary data from a rural community-based study undertaken in 1995 and secondary data from the South African National Primary Schools (SANPS) survey conducted in 1994. Stunting was measured according to the WHO definition of -2 Z scores height-for-age. Two sets of criteria were used to measure overweight and obesity-the WHO/NCHS standard based on the 85th and 95th centiles and the IOTF criteria. SETTING: The primary data source was from a rural KwaZulu-Natal community based survey. The secondary data source SANPS consisted of data at National and Provincial level; for this study only data from the province of KwaZulu-Natal was considered. SUBJECTS: Primary school children aged between 8 and 11 y of age; 802 from the primary data source and 24 391 from the secondary source. RESULTS: Moderate stunting ranged from 2.9 to 40.2%, and mild stunting ranged from 31.4 to 75%. The prevalence of overweight ranged from 0.4 to 13.3% (WHO criteria) and from 0.4 to 11.9% using the IOTF criteria; while obesity ranged from 0.1 to 3.7% (WHO) and from 0.1 to 1.5% (IOTF criteria). The prevalence of overweight and obesity was observed to be higher using the WHO definition than that of IOTF (0.050.55, in all cases). The levels of agreement in all cases were less for obesity than overweight (both ranged from 0.55 to 1.0). Females were observed to have higher kappa levels than their male counterparts; they also had higher prevalence levels of overweight and obesity across age and geographical group. Uniformly high levels of both mild and moderate stunting were observed both nationally and provincially. However, no excess relative risk of being overweight if stunted was observed in this study (P>0.05). CONCLUSIONS: Caution must be applied when using either definition for obesity. However, very high levels of agreement occur for overweight. There is no obvious relationship between overweight and stunting in this study, but high levels of mild stunting were observed. Regular clinical and epidemiological monitoring of nutritional status needs to be undertaken in South Africa to examine possible future trends of overweight/obesity and their relationship with stunting, and for comparisons with global trends.

A randomized controlled trial of the effect of antihelminthic treatment and micronutrient fortification on health status and school performance of rural primary school children.

Single interventions for helminthic infections and micronutrient deficiencies are effective, but it is not clear whether combined interventions will provide equal, additive or synergistic effects to improve children's health. The study objective was to determine the impact of single and combined interventions on nutritional status and scholastic and cognitive performance of school children. A double-blind, randomized, placebo-controlled trial in 11 rural South African primary school randomly allocated 579 children aged between 8 and 10 years into six study groups, half of whom received antihelminthic treatment at baseline. The de-wormed and non-de-wormed arms were further divided into three groups and given biscuits, either unfortified or fortified with vitamin A and iron or with vitamin A only, given daily for 16 weeks. The outcome measures were anthropometric, micronutrient and parasite status, and scholastic and cognitive test scores. There was a significant treatment effect of vitamin A on serum retinol (p < 0.01), and the suggestion of an additive effect between vitamin A fortification and de-worming. Fortified biscuits improved micronutrient status in rural primary school children; vitamin A with de-worming had a greater impact on micronutrient status than vitamin A fortification alone and antihelminthic treatment significantly reduced the overall prevalence of parasite infection. The burden of micronutrient deficiency (anaemia, iron and vitamin A) and stunting in this study population was low and, coupled with the restricted duration of the intervention (16 weeks), might have limited the impact of the interventions.

The effect of different anthelmintic treatment regimens combined with iron supplementation on the nutritional status of schoolchildren in KwaZulu-Natal, South Africa: a randomized controlled trial.

A randomized controlled trial in KwaZulu-Natal (South Africa) of 428 primary-school pupils (stratified into 6 groups by age, sex and intervention) measured the effect of different anthelmintic treatments and iron supplementation regimens provided twice at 6-monthly intervals for 1 year (1996/97). Half the pupils received iron supplementation (ferrous fumarate 200 mg weekly for 10 weeks). Pupils received 2 anthelmintic regimens, either (i) albendazole 400 mg plus praziquantel 40 mg/kg or (ii) albendazole 400 mg on 3 consecutive days plus praziquantel 40 mg/kg or (iii) placebo. Baseline prevalences of Ascaris 55.9%, Trichuris 83.6%, hookworm spp. 59.4%, were reduced after 12 months for single-dose albendazole treatment to Ascaris 17.4% (P < 0.005), Trichuris 61.5% (NS), hookworm spp. 0% (P < 0.005), and for triple-dose albendazole treatment to Ascaris 14.8% (P < 0.005), Trichuris 25.0% (P < 0.01), hookworm 0% (P < 0.005). Schistosoma haematobium 43.4% was reduced among treated groups to 8.3% (P < 0.005). There were no significant changes in the anthropometry of the different treatment groups at either 6 or 12 months post treatment. Twelve months after treatment there was a significant increase in haemoglobin levels (P = 0.02) among pupils receiving triple-dose albendazole, praziquantel and ferrous fumarate; pupils receiving no anthelmintic treatment showed a significant decrease as did pupils who received triple-dose albendazole and praziquantel but no iron. Regular 6-monthly anthelmintic treatment significantly reduced the prevalence of Ascaris, hookworm spp. and S. haematobium infections (P < 0.05). Triple-dose treatment for Trichuris was significantly more effective than a single dose of albendazole 400 mg (P = 0.002). In areas with schistosomiasis, hookworm infection and high prevalence of Trichuris infection, combination treatment with praziquantel, triple-dose albendazole, plus iron supplementation, is likely to improve pupils' health and haemoglobin levels.

A health and nutritional profile of rural school children in KwaZulu-Natal, South Africa.

A community-based cross-sectional study was undertaken to measure anthropometric indices, micronutrient status and prevalence of parasite infections in 579 rural South African primary school children. Eleven schools were selected randomly from a Magisterial District in southern KwaZulu-Natal (KZN). In each school, all pupils aged between 8 and 10 years were selected. The following outcome measures were obtained: anthropometric--height for age, weight for age and body mass index; micronutrient status--anaemia, serum ferritin and vitamin A; and prevalence of parasite infections--Ascaris lumbricoides, Trichuris trichiura and Schistosoma haematobium. The observed prevalences were: stunting 7.3%, underweight for age 0.7%, and obesity 3.1%; anaemia 16.5% (Hb < 12 g/dl), vitamin A deficiency 34.7% (serum retinol < 20 micrograms/dl) and 28.1% with reduced serum ferritin (< 12 ng/ml); Trichuris trichiura 53.9%, Ascaris lumbricoides 27.3% and Schistosoma haematobium 24.5%. We conclude that micronutrient deficiency, parasitic infestations and stunting remain significant problems among school-aged children in South Africa. Micronutrient supplementation and de-worming provide opportunities for school-based health promotion and primary health care interventions, and might produce significant health and educational benefits.

Epidemiology of helminth infections: implications for parasite control programmes, a South African perspective.

OBJECTIVES: To determine the epidemiology of helminthic infections and the efficacy of parasite treatment among rural South African primary school children in the province of KwaZulu-Natal. To assess the South African government's parasite control policy. METHODS: The study recruited 268 school children, aged 8 to 10, and randomly allocated them into treatment and placebo groups (treatment consisted of a single dose of albendazole (400 mg) and praziquantel (40 mg/kg)). Anthropometric measurements and the prevalence and intensity of helminth infections were taken at baseline (prior to treatment) and 16 weeks post treatment. Two weeks after treatment prevalence and intensity were again measured for an approximate 50% sub-sample of the children to investigate efficacy of treatment. An analysis of the South African government's policies concerning parasite control is assessed in the light of these epidemiological findings. RESULTS: Low levels of both stunting and wasting were observed throughout the study (approximately 10% and 1%, respectively), but did not vary significantly across either treatment group or time period (P >0.50). At baseline the observed prevalences for the three main helminths found in this study among the treated children were Ascaris lumbricoides 29.5%, Trichuris trichiura 51.9% and Schistosoma haematobium 22.3%. These prevalences declined significantly to 4.7% (P <0.0005), 38.0% (P < 0.03), and 3.3% (P < 0.0002), respectively, 16 weeks post treatment. The majority of infections observed at baseline were of light intensity, namely A. lumbricoides (50%), T. trichiura (80%) and S. haematobium (100%), and following treatment these levels were reduced significantly (P <0.0001, P< 0.05 and P < 0.005, respectively). The levels of both prevalence and intensity in the untreated group remained constant. The cure rates over the first two weeks of the study were found to be 94.4% for A. lumbricoides, 40% for T. trichiura and 72.2% for S. haematobium. CONCLUSION: The benefits of targeted, school-based treatment in reducing the prevalence and intensity of infection supports the South African government's focus of using school-based interventions as part of an integrated parasite control programme. These strategies and programmes are consistent with recommendations of the World Health Organization (WHO) and The United Nations Children's Fund (UNICEF).

Prevalence of asthma and respiratory symptoms in south-central Durban, South Africa.

The prevalence of asthma and respiratory symptoms in south-central Durban, one of the most heavily polluted areas of South Africa, has been determined using a cross-sectional survey of 213 households in the communities of Merewent (97% Indians) and Austerville (98% coloreds). The study population consisted of 367 children (less than 17 years old) and 693 adults. About 10% of the children and 12% of adults reported doctor diagnosed asthma. The self-reported prevalence rates for wheezing (3740%) and attacks of shortness of breath with wheeze (16-28%) were much higher than that for doctor diagnosed asthma and common co-occurrence of the three symptoms is found. The prevalence rates for other respiratory symptoms include 33-35% for chronic cough, 31-32% for chronic phlegm, 44-50% for frequent blocked-runny nose, and 16-27% for sinusitis. Factors in the community that were associated with asthma, wheeze and shortness of breath with wheeze among the adult population included cigarette smoking, use of insecticides (coils and pump spray) and home ownership. An association between asthma among children and a number of household risk factors including dampness, carpet, pets or use of pesticides was not apparent in the community. Asthma prevalence was strongly correlated with missing of school by children (odds ratio (OR): 44; 95% confidence interval (CI): 13-141). The study serves to draw attention to a growing but neglected public health problem in urban areas of Africa.

Helminth control as an entry point for health-promoting schools in KwaZulu-Natal.

OBJECTIVES: To use a health promotion model to investigate the risk factors (predisposing, enabling and reinforcing) for geohelminth and schistosomiasis infections, in order to develop and implement effective intervention strategies. DESIGN: Phase 1: Qualitative study using focus group discussions (FGDs) with parents, pupils and teachers; and interviews with health workers. Phase 2: Quantitative study using a semi-structured questionnaire to investigate whether the determinants identified in phase 1 were generalisable. SETTING: Rural primary schools in Vulamehlo magisterial district, southern KwaZulu-Natal. STUDY POPULATION: Qualitative study: 9 schools with 179 pupils, 93 parents and 82 teachers; and local clinics (4 fixed, 1 mobile), with 7 professional nurses. Quantitative study: 2 other schools, with 730 pupils. RESULTS: Predisposing factors: Respondents were familiar with symptoms, but did not know the cause or mode of transmission of helminth infections. Many respondents perceived food to be the cause of geohelminth infection and swimming in the river to be the cause of schistosomiasis. Although 649 (88.9%) pupils had toilets at home and at school, only 218 (29.9%) were motivated to 'always' use the toilet for faecal disposal (rural communities previously did not have toilets). Six hundred and seventy-eight pupils (92.9%) understood that it was necessary to wash their hands after using the toilet, but many schools lacked water. Personal cleanliness was a problem despite the emphasis on hygiene by health workers and teachers. Few pupils admitted to eating soil, but it was agreed that geophagia affected young children between the ages of 8 months and 6 years. Enabling factors (positive/negative): Barriers to health promotion frequently included inadequate toilet facilities at school and home, and river-water contact resulting from a lack of clean water. A dearth of recreational facilities resulted in children swimming and playing in the river. Positive factors were the health-seeking behaviour of the majority of the target group, who identified helminth infections as a health problem and sought treatment. Parents and pupils in the FGDs unanimously supported health education and 655 (89.8%) questionnaire respondents indicated that they wished to learn how to avoid helminth infections. CONCLUSIONS: Although the Government strategy is to provide clean water and adequate sanitation, provision of services does not necessarily ensure usage. A comprehensive approach to health promotion is required and the complementary development of the 'health-promoting school' would support, reinforce and sustain a helminth control programme.

Development of a health programme in a peri-urban informal settlement in Besters, KwaZulu-Natal.

OBJECTIVES: The demographic, socio-economic and environmental status of the peri-urban informal settlement of Besters and its inhabitants' health, welfare and disability profiles were investigated for the development of a community-based health intervention programme. STUDY DESIGN: A cross-sectional study using a structured household questionnaire assessed community health status in July 1991 in order to identify specific health and development needs through focus group discussions and community consultations. A health and development programme was established during 1992. Community participation in this programme was then assessed by measurement of the components of the health and development programme, categorised as inputs (resources), processes (activities), outputs (effects) and outcomes. SETTING: Besters, an informal peri-urban settlement north of Durban, KwaZulu-Natal. SUBJECTS: Residents of Besters. RESULTS: The demographic, environmental and morbidity profiles of Besters were consistent with both South African and international studies of informal communities. Patterns of health service utilisation reflected inappropriate use of the tertiary hospital in the city centre, grossly fragmented patterns of utilisation--both for preventive and curative care and for antenatal and maternity services--and, finally, a discordance between community health needs and ability to pay for services. The interaction between input, process and output measures of community participation are discussed. CONCLUSION: Integration of health service provision with other infrastructural development, based on community perceptions, enhances health development and community participation. Important lessons emerged about the strengths and limitations of community participation and its relevance for other communities.