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.

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.

Vitamin A deficiency among children in a periurban South African settlement.

Preschool children (aged 3-6 y) who were living in an informal settlement within metropolitan Durban, South Africa, were assessed for vitamin A status. The serum retinol concentration of 169 children tested was 0.73 +/- 0.26 mumol/L (mean +/- SD). Nine children (5%) had vitamin A deficiency (< 0.35 mumol/L) and 75 children (44%) had low vitamin A concentrations (< 0.70 mumol/L). Conjunctival impression cytology (CIC) in 185 children revealed that 18% had poor vitamin A status as defined by two abnormal conjunctival specimens. The CIC test was a feasible and reproducible method; however, it correlated poorly with the traditionally accepted serum retinol threshold of deficiency in this population where overt vitamin A deficiency is not prevalent. This survey demonstrated that regardless of the measurement tool, there is a prevalence of subclinical vitamin A deficiency in this typical periurban informal settlement and accordingly we suggest that these children should be targeted for vitamin A-intervention strategies.

Markers of hepatitis B in nurses and domestic staff in an area of high endemicity.

Results obtained in two sero-epidemiologic surveys of hospital personnel in Durban were collated to yield information on 423 nurses and 141 domestic staff. The prevalence of antibodies to HBV was 14.9 per cent in 101 white nurses, 52.5 per cent in 322 African nurses and 51.8 per cent in 141 African domestics. This represents a greater than eight times increase for white nurses and a 50 per cent increase for African nurses and domestics over that seen in the equivalent blood donor groups (P less than 0.001 in each case). Antibody prevalence increased with age for all three staff groups, as did the number of individuals exhibiting a marker pattern (HBcAb greater than HBsAb) suggestive of persisting infection. No white nurses but 14 (4.3 per cent) African nurses and 17 (12.1 per cent) African domestics were HBsAg positive, the antigenaemia in domestics representing a significant increase (P less than 0.001) over the 4.0 per cent seen in female African blood donors. Six of the nurses and two of the domestics were also HBeAg positive. African nurses in adult medical wards showed greatest exposure (57 per cent) closely followed by nurses working in outpatient departments (54 per cent) and as theatre staff (52 per cent). Lower exposure rates (40 per cent) were seen in paediatric and renal unit nurses. This contrasts with results obtained for doctors in the two surveys which indicated that while Indian and white doctors are at significantly higher risk in the African hospital, African doctors are not, and that doctors working in surgical and renal departments are at higher risk than doctors on adult medical wards.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

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.

Lead poisoning of children in Africa, II. Kwazulu/Natal, South Africa.

The prevalence of elevated blood lead (PbB) levels in rural and semi-urban areas of Kwazulu/Natal (KZN) as well as the risk factors for elevation of PbB among children in informal settlements are examined. The study involved over 1200 children in two age groups: 3-5 and 8-10 years old. Average PbB level in Besters, an informal settlement in the Durban metropolitan region, was 10 micrograms/dl with 5% of the children showing PbB level of greater than 25 micrograms/dl. By comparison, average PbB value in Vulamehlo, a rural area located 90-120 km from Durban, was 3.8 micrograms/dl and 2% of the PbB was greater than 10 micrograms/dl. The results show that many children in KZN are at risk of being lead poisoned. Household factors that were significantly associated with PbB levels in children included distance from tarred roads, overcrowding, hygienic habits in the household and the burning of solid wastes for heating or cooking. Lack of significant association with child risk behaviors is attributed to the over-riding influence of high levels of contaminated dusts both indoor and outdoor. With recent introduction of unleaded gasoline in South Africa, a number of unique socio-ecological factors are expected to slow the change in PbB levels of children in some townships.

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.

Socio-medical indicators of health in South Africa.

Socio-medical indicators developed by WHO for monitoring progress towards Health-for-All have been adapted to reveal, clearly and objectively, the devastating impact of state planning based on an outmoded immoral and unscientific philosophy of race superiority in South Africa on the health of the disenfranchised majority within the context of social and economic discrimination; Health policy indicators confirm that the government is committed to three options (Bantustans, A New Constitution, and A Health Services Facilities Plan) all of which are inconsistent with the attainment of Health-for-All; Social and economic indicators reveal gross disparities between African, Coloured, Indian, and White living and working conditions; Provision of health care indicators show the overwhelming dominance of high technology curative medical care consuming about 97 percent of the health budget with only minor shifts towards community-based comprehensive care; and Health status indicators illustrate the close nexus between privilege, dispossession and disease with Whites falling prey to health problems related to affluence and lifestyle, while Africans, Coloureds, and Indians suffer from disease due to poverty. All four categories of the indicator system reveal discrepancies which exist between Black and White, rich and poor, urban and rural. To achieve the social goal of Health-for-All requires a greater measure of political commitment from the state. We conclude that it is debatable whether a system which maintains race discrimination and exploitation can in fact be adapted to provide Health-for-All.

PIP: This report evaluates the effects of race discrimination on the health status of South Africa using a socio-medical indicator system derived by WHO. The indicator system consists of 4 categories: health policy indicators, social and economic indicators related to health, indicators of provision of health care, and health status indicators. Political commitment is essential for the attainment of health for the population; the government of South Africa is committed to 3 different options influencing health, all described in detail. Budget allocation is an objective measure of commitment; 3.2% of the GNP was spent on health in 1981, and only 2.2% of the total health budget is devoted to preventive medicine. Absence of democratic structures for all to express needs and demands results in racially biased allocation and distribution of health services. Social and economic indicators relating to health include rate of population increase, gross national product, income distribution, work conditions, literacy rates, housing needs, and food availability. Indicators of basic health status include nutritional status, child mortality rates (15.6/1000 for Africans, 1.1 for whites) and life expectancy at birth (for black males 45.0 yrs and for black females 47.3, for white males 65.5 and white females 71.9). In order to achieve health for all, action is needed at the political level to eliminate apartheid, and at policy and decision making levels, to improve living and health conditions.

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.

Cost analysis of the basic package, resource utilisation and financing of health services at Halley Stott Health Centre and Umbumbulu Clinic in KwaZulu-Natal.

OBJECTIVES: A cost analysis study compared the package of health services, costs, resource utilisation (drugs and staff) and financing mechanisms at Halley Stott Health Centre and Umbumbulu Clinic with those of other primary care providers in KwaZulu-Natal. Options identified were used to improve efficiency, resource allocations and financing of health services in KwaZulu-Natal. DESIGN/OUTCOME MEASURES: The direct accounting method was used to calculate unit costs for the following cost centres--paediatrics and adult curative consultations, antenatal/postnatal care, family planning, the under-5s clinic and the mobile services. Staff efficiency was assessed using the Centre for Health Policy method based on workload estimates, while the International Network for the Rational Use of Drugs indicators were used to assess the efficiency of drug usage. RESULTS: There was considerable variation in the package of services provided at all the health facilities; the average costs ranged from R5.94 to R134.76 and the unit costs ranged from R29.30 to R161.92 for curative care. The bulk of the resources (64-73%) were spent on personnel costs, providing mainly curative care. Under-utilisation of antenatal care, the under-5s clinic and paediatric consultations were reflected in reduced time utilisation and lower levels of staff efficiency, while family planning services were over-utilised, which reflected a relative staff shortage. The components of health services provided at the two health facilities exceeded those recommended by the World Bank. CONCLUSIONS: Cost analysis has the potential to quantify staff and drug efficiency, facilitate resource allocation and improve health service efficiency. Defining the package of health services for each province contributes to the development of the nationally agreed basic package of health services, and enables managers and policy-makers to choose different options rationally, control costs, shift resources and achieve equity.

Health personnel needs and attitudes to rural service in KwaZulu-Natal.

OBJECTIVES: To ascertain the urban/rural distribution of health personnel and the opinions of the medical fraternity in KwaZulu-Natal on compulsory rural service for medical practitioners. DESIGN: Cross-sectional analysis of geographical distribution of health personnel in KwaZulu-Natal based on 1991/92 South African Medical and Dental Council, South African Nursing Council and Pharmacy Council registration data. Opinion survey by administration of a structured questionnaire to a simple, random sample of private practitioners, academic consultants, postgraduate and undergraduate medical students and key informants in senior health service management in KwaZulu-Natal. RESULTS: Peripheral rural areas had health personnel/population ratios higher than or equivalent to those of urban areas, whereas the ratios were 15-40 times lower in deep rural areas. The key finding of the opinion survey was that the majority of all sectors except fifth-year medical students felt that rural service should be compulsory, either post-internship, prior to specialisation or prior to entry into private practice. However, respondents were significantly more likely to agree to rural service that would not affect them personally. The majority (54-87%) of all sectors felt that an option of 'buying out' of rural service should not be permitted. Respondents identified a range of financial, health service, academic, infrastructural and social incentives for rural practice. It is recommended that post-internship rural service be compulsory for a period of 6 months to 1 year provided that academic, health service and infrastructural deficiencies are ameliorated and appropriate financial incentives are provided.

Priority health problems of children in an urban community.

A survey was conducted in an urban Indian community to investigate the prevalence and epidemiology of health problems in children from birth up to 8 years of age. The prevalences of priority health problems in this age group were as follows: dental caries (90%), undernutrition (68,8%), failure to obtain measles immunization (57,2%) and skin infestations (14,9%). The significant epidemiological parameters investigated included family size, per capita family income, immunization and nutritional status. The influence of these factors upon health problems is considered. The availability and utilization of comprehensive health services were investigated. Problems associated with health screening as a method of determining health problems are discussed.

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.

Determining appropriate nutritional interventions for South African children living in informal urban settlements.

Rapid urbanisation in South Africa has led to the creation of informal shack settlements where the health status of children is in jeopardy; it needs to be monitored so that appropriate intervention strategies can be formulated. Accordingly, the nutritional status of 190 children (3-6 years of age) living in Besters, a typical urban shack settlement north of Durban, was assessed anthropometrically. In addition the following biochemical values were determined: vitamins A and E, calcium, magnesium, phosphorus, albumin, haemoglobin, serum iron and ferritin and percentage of transferrin saturation. Malnutrition was evident in 13% of the children who were underweight (below the National Center for Health Statistics (NCHS) third weight-for-age percentile) and 27% who were stunted (below the NCHS third height-for-age percentile). Concentrations of albumin, calcium, magnesium, phosphorus and vitamin E were close to normal, with no more than 10% of the sample having values outside the normal range. However, 44% of the children had low serum retinol levels (< 20 micrograms/dl) and 21% of the children had anaemia (haemoglobin < 11 micrograms/dl). Significant positive correlations were found between serum retinol and all biochemical indicators of iron status except serum ferritin. This study highlights the fact that nutrient deficiencies are interrelated, particularly protein energy malnutrition and poor vitamin A and iron status. A broad multifaceted comprehensive health intervention programme is therefore required.

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.

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.