Search

Objective Literature on human resources for health in Africa has focused on personal health services. Little is known about graduate public health education. This paper maps "advanced" public health education in Africa. Public health includes all professionals needed to manage and optimize health systems and the public's health. Methods Data were collected through questionnaires and personal visits to departments, institutes and schools of community medicine or public health. Simple descriptive statistics were used to analyse the data. Findings For more than 900 million people, there are fewer than 500 full-time staff, around two-thirds of whom are male. More men (89%) than women (72%) hold senior degrees. Over half (55%) of countries do not have any postgraduate public health programme. This shortage is most severe in lusophone and francophone Africa. The units offering public health programmes are small: 81% have less than 20 staff, and 62% less than 10. On the other hand, over 80% of Africans live in countries where at least one programme is available, and there are six larger schools with over 25 staff. Programmes are often narrowly focused on medical professionals, but "open" programmes are increasing in number. Public health education and research are not linked. Conclusion Africa urgently needs a plan for developing its public health education capacity. Lack of critical mass seems a key gap to be addressed by strengthening subregional centres, each of which should provide programmes to surrounding countries. Research linked to public health education and to educational institutions needs to increase. [ABSTRACT FROM AUTHOR]

During November 1985 a survey was carried out to determine the prevalence and causes of blindness in the Elim Hospital district of Gazankulu in the Northern Transvaal, South Africa, and to assess the Eye Department's effectiveness in preventing blindness. Using a random cluster sample technique, we screened 18,962 of the estimated 71,200 inhabitants of the district (26.6%). We found 109 blind people. The prevalence of blindness was 0.57% (95% confidence interval 0.46%-0.68%). The main causes of blindness were senile cataract (55%), corneal scarring due to trachoma (10%), uncorrected aphakia (9%), and open-angle glaucoma (6%). There were 14 aphakic blind persons who did not have aphakia glasses (43% of all persons operated on for cataract). Women had a significantly higher prevalence of blindness than men. After the age of 60 years the prevalence of blindness increased sharply. Women were 1.6 times less likely to have undergone cataract surgery than men. The two most effective steps to reduce the prevalence of blindness in the Elim district further are to provide aphakia glasses to all aphakic patients and to improve the accessibility of the Eye Department's surgical services. [ABSTRACT FROM PUBLISHER]

Over the past 25 years, the ethics of international health research have shifted from addressing narrow issues such as cultural differences in informed consent practices towards a greater emphasis on development and social justice. We anticipate that the next 'era' in international research ethics will involve an intensification of this focus on the role of research in achieving global justice. Three values, in particular, will shape how ethics considerations should evolve: solidarity; respect for Southern innovation; and commitment to action. We expect continuing debate on whether researchers and research sponsors should recognise more than a minimal set of obligations for the care and benefit of research participants and their communities. As the debate about the role of research in development intensifies, we expect to see new and more elaborate mechanisms for financing on-going access to beneficial interventions, ancillary care and other research-related benefits, as well as a greater involvement in research funding by developing country governments and private foundations. Ethics review and oversight need to reflect on these new values and on ways of operationalising them, or risk becoming marginalised in the research process.

Objectives: The purpose of this study was to establish the proportion of pharmacies providing screening tests in the areas of Pretoria, Potchefstroom and Klerksdorp, the types of tests used and their cost to patients, the criteria employed to select high-prevalence groups, the attitudes of pharmacists towards screening, and their knowledge of test characteristics., Setting: In Pretoria, 155 pharmacies were randomly selected and all 43 pharmacies in Potchefstroom and Klerksdorp were included., Methods: The pharmacies included in the study sample were first contacted by telephone to identify those providing screening tests. Pharmacies that provided screening tests and agreed to participate in this study were then visited and a questionnaire was administered., Results: 57% of the pharmacies provided at least one type of screening test. Blood pressure measurement, serum cholesterol, capillary glucose and pregnancy testing were the most common screening tests available. With the exception of blood pressure measurement, the screening tests were conducted less than 5 times per week. All respondents referred clients with abnormal results to general practitioners but only 35% of pharmacies kept records of the patients tested and the test results. The knowledge of pharmacists concerning the important features of screening tests, such as false-positive and false-negative rates, was poor. No quality control procedures for the screening tests were employed., Conclusions: Providing pharmacists with specific training in the application and interpretation of screening procedures, and implementing quality control measures will reduce the number of false referrals or non-referrals, and will improve the quality of the service. If pharmacies are to play a meaningful role in screening for disease, coverage of the population will need to be increased substantially.

Objective: This article aims: (i) to re-examine the use and usefulness of categorisation based on 'race', ethnicity and 'population group' membership in public health research; and (ii) to assess the consequences of using these categories for describing, analysing and redressing disparities in health within South Africa. The utility of categorisation based on 'race', ethnicity and 'population group'. Categorising populations and comparing patterns of disease between different groups of people can be a useful technique for identifying potential causes of disease. In this context, ethnicity is a valid social concept that could be used to investigate the consequences of self-ascribed identity on health. Likewise, 'population group', as defined during apartheid in South Africa, represents a valid political concept that could be used for assessing the impact of social discrimination on health. However, both these concepts are often seen, and used, as euphemisms for 'race', even though there are no genetically distinct human subspecies that can be identified and categorised as discrete 'races'. Indeed, 'race' as a biological concept has no validity in human biology. Nevertheless, categories based on 'race', ethnicity and 'population group; continue to be used in health research, and reinforce the perception that differences in disease between different 'racial', ethnic and 'population' groups are the result of heritable biological characteristics. In so doing, they undermine support for health interventions that would otherwise address the social and political origins of 'racial' and ethnic disparities in health. The utility of 'population group' for redressing the consequences of apartheid. Despite these problems, 'population group' classification provides important information for assessing the impact of apartheid on disparities in health within South Africa. Yet, the abolition of apartheid legislation is likely to result in extensive socio-economic and geographical migration that will weaken the sensitivity and specificity of 'population group' as an indicator for identifying inequalities in health. For this reason, targeting corrective action at specific population groups in order to tackle disparities in health, runs the risk of ignoring alternative social causes of inequalities in health, and ignoring disadvantaged individuals from elsewhere in the population. The continued use of 'population group' classification might also perpetuate the root cause of disparities in health, by maintaining the process used to formalise discrimination., Conclusion: If the purpose of health research is to monitor inequalities in health and to help target resources aimed at reducing these inequalities, then it should seek, in its language, concepts and methods to undermine the root cause of disadvantage. Health research aimed at monitoring and redressing the consequences of social disadvantage on health should therefore focus on non-biological determinants of social disparities in health. As a general rule, health researchers should avoid using categories based on 'race', ethnicity and 'population group' when collecting and analysing health data; journal editors should not accept articles that use these categories without justification; and health authorities should not collect data routinely segregated by 'race', ethnicity or 'population group'.

Objective: To assess the statistical procedures used in original papers published in the SAMJ., Design: Descriptive study based on a random sample of 100 papers from the 153 papers with methodological content that were published in the SAMJ during 1992., Results: This review showed that 34% (95% CI (25%; 43%)) of papers used no statistical procedure at all or used simple descriptive statistics only. In sampling methods, there was a predominance of the use of the period sampling method as opposed to probability sampling methods. Inappropriate statistical methods were used in 15% (6%; 24%) of papers, while in 16% (9%; 23%) statistical procedures and in 13% (6%; 20%) the sampling methods used could not be identified. Inaccurate graphical methods were used in 17% (6%; 28%) of papers. Confidence intervals and power calculations are used far too infrequently, in 33% (19%; 47%) and 11% (3%; 19%) of appropriate papers respectively. If the Journal's readers are at least familiar with simple descriptive statistics, contingency table analysis, simple epidemiological statistics, t-test procedure and confidence interval calculation and interpretation, they will have a complete understanding of the statistical content of 60% of original articles published in the Journal., Conclusion: Guidelines for the statistical treatment of reported data and the statistical review of articles before publication will assist substantially in improving the quality of statistical analysis. More intensive use of available biostatistical and epidemiological expertise at the study design and analysis stages is needed to shift the emphasis from descriptive research to analytical investigation.

Recent epidemics of poliomyelitis and measles in the Edendale/Vulindlela district of KwaZulu spurred an investigation into the causes of vaccination failure. Vaccination coverage achieved by routine clinic services and by two mass campaigns was assessed. The validity of routine clinic vaccination records was also determined. Using a modified 30 x 7 random cluster sampling technique, 224 children aged 1-5 years were studied. Of these, 62% had a 'Road to Health' card. Best estimates show that 87% had had BCG, 62% three doses of diphtheria, pertussis and tetanus and polio, and 55% measles vaccine. The mass campaigns raised coverage for measles by 26%, and that for polio by 27%. Coverage estimates made from routine clinic data were consistently 13-25% higher than from this survey. This discrepancy is unfortunate, since it could lead to complacency if certain targets are apparently achieved using only clinic records, and points to the need for regular population-based surveys in all but the best organised health services. Inadequate vaccination coverage alone can explain the epidemics of polio and measles. The reasons for this, in the presence of an adequate clinic infrastructure, need to be assessed urgently to prevent further outbreaks.

Seroprevalence was used to evaluate the vaccination programme in the Elim health ward of Gazankulu. Antibodies to measles and polio were measured in 1-6-year-old children together with vaccination status. In 224 children studied using a cluster sampling technique, vaccine coverage was found to be 86% for measles and over 90% for polio and diphtheria, pertussis and tetanus. It was difficult to determine vaccine failure rates accurately; 21% of children were seronegative after having received measles vaccine, 32% who had apparently not been vaccinated had antibodies, while a total of 27% had no measles antibodies. Thirty-nine per cent of children failed to demonstrate antibodies to all 3 types of poliovirus after having received 3 doses of oral polio vaccine, 94% had immunity against type 2, and 76% and 74% were immune to types 1 and 3, respectively. Reasons for diminished effectiveness of vaccination programmes are cited; in this study it was probably due to decreased vaccine efficacy related to inadequacies in the cold-chain. Recommendations are that seroprevalence studies are useful, but only after vaccine coverage and the cold-chain have been optimised.

The Chamber of Mines of South Africa employs approximately 750,000 miners from all over southern Africa. Sero-surveys in 1986 showed that, depending on geographical area of origin, between 0.02% and 3.76% of miners were positive for human immunodeficiency virus (HIV) antibodies. As a consequence, an intensive education campaign to stop the spread of HIV infection was launched. A study was undertaken to establish a valid baseline level of knowledge about black miners' beliefs, attitudes and practices related to HIV infection, acquired immunodeficiency syndrome (AIDS) and sexually transmitted diseases (STDs), and to recommend appropriate changes to the educational efforts of the Chamber of Mines. A structured, pre-tested questionnaire was used to interview in their home language 429 systematically sampled black miners from four different mines. The most relevant findings were that younger age, not being married and how general education predispose to contracting STDs, while a feeling of being at risk for contracting HIV infection is positively correlated with level of education. Close friends were the most important source of information on STDs, but the media and medical staff were the most important sources of information on AIDS/HIV infection. Condoms were used by 31% of respondents, while the main reasons for non-use were trust in the sexual partner and lack of availability. Promotion of a stable family life for miners may significantly impact on the transmission of HIV infection.

In January 1989, the Johannesburg City Health Department developed an AIDS education poster. The poster was adapted from a cartoon in the Sowetan newspaper and was formally evaluated before its final production. As a result of this evaluation further editing and restructuring of the poster proved necessary. The methodology used in the evaluation is outlined, and some of the findings that emerged during the evaluation are discussed, since few formal evaluations of health education material seem to have been documented in South Africa. This study highlights the importance of formative evaluation of printed health educational media by a sample of the target audience before production and distribution.

Local authorities (LAs) currently provide preventive and promotive services. It is argued that, by extending the role of the LA to the provision of comprehensive services, including ambulatory and hospital curative care, both the quality and the cost-effectiveness of health care would be improved. Making health care the responsibility of the LA would minimise fragmentation, allow for the provision of a number of services that currently are neglected because they fall through the gap that exists between preventive and curative services, and result in the more effective use of personnel currently restricted to providing preventive care only. LAs offer an appropriate structure for effective community control over the health services, and are more likely to be sensitive to local needs and demands. In addition, their administrative proximity to other LA departments responsible for housing, town planning and parks and recreation allows for an effective multisectoral approach to health. The positive aspects of LA care can only be achieved in the context of racially integrated services provided by an LA elected by universal adult franchise. Smaller LAs may need to be grouped together in larger units for the purpose of achieving satisfactory economies of scale in the provision of health care.

A cross-sectional study of the nutritional status of 658 children under 5 years of age was carried out in one district in Gazankulu. Of these children, 29,8% were below the 3rd percentile of weight for age of the 1976 National Center for Health Statistics standards; in the 1 - 2-year age group this figure was 38,2%. A small group, 1,8%, weighed less than 60% of expected weight for age. The presence of a clinic in a village seems to have no influence on the percentage of underweight children.

In this, the second of a three-part series of articles in which we propose steps towards a comprehensive strategy for the control of HIV infection, we consider controversies relating to screening for HIV, the indications for and desirability of mandatory testing of certain groups at risk, and the place of voluntary testing in the control of HIV transmission and infection. Key recommendations are that mandatory testing of donors of blood and other vital tissues, patients on haemodialysis and haemodialysis unit staff is justified, and that children put up for adoption may require testing. We make further recommendations regarding HIV testing as a prerequisite for life insurance and recommend that voluntary testing be offered, supported by adequate pre- and post-test counselling. We consider that all health care workers should accept as their moral obligation the care and management of HIV-infected individuals, and that they should be adequately educated and skilled in such work. These recommendations were reached largely by consensus, although there were occasions when individual authors condoned recommendations with which they did not personally agree.

Oral rehydration therapy (ORT) is effective in preventing dehydration during acute gastro-enteritis, thus decreasing morbidity and mortality. There is, however, reluctance among mothers and child-minders to use ORT when faced with the crisis of acute diarrhoea. This study describes the effects of a health education campaign, using the Morley (sugar and salt) spoon, on knowledge and practice of ORT in one community in Gazankulu, and compares care group (CG) with non-care group (non-CG) members. Two years after its introduction, the Morley spoon was still the most commonly used method of preparing oral rehydration solution (ORS). Ninety-seven per cent of CG members could produce the spoon when asked to, as opposed to 55% of non-CG members (P less than 0.001). Eighty-two per cent of respondents had actually used ORT in the past. Fifty-three per cent mixed the ORS incorrectly. Sixty-one per cent believed that ORT would stop diarrhoea and 29% that it was used for rehydration. Only 26% would give ORS after every loose stool, but 54% would give ORT until the diarrhoea has stopped. Fifty-nine per cent of women would feed their children soft porridge, 20% would continue breast-feeding, and 2% would starve the child while it had diarrhoea. Women who had retained the Morley spoon showed a greater knowledge of ORT (P less than 0.005) and had used ORT more often in the past (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

An assessment of the immunisation status of children under the age of 5 years in the Elim health ward was undertaken in September 1985. A modified EPI technique for random cluster sampling was used. The advantages of this modification are discussed. In total, 480 children were selected. Of these, 83.5% possessed a 'Road to Health' card, 93.5% had had 3 or 4 doses of DPT vaccine, 92.1% had had 3 or 4 doses of polio vaccine, and 84.3% had had 1 dose of measles vaccine. The percentage of children of 18 months and older who received a fourth dose of either DPT or polio vaccine was 65.9% and 68.5% respectively. The vaccination status of younger children is better than that of older children and this is probably due to recent improvements in the vaccination services. It is recommended that the proportion of children who receive a fourth dose of DPT and polio vaccine should be increased and that completed vaccination is made an entrance requirement for primary schools.

The objectives of this study were to document the official oral fluid therapy (OFT) policies of all the ministries of health in South Africa and of the four provincial authorities, to determine what methods of OFT are used in hospitals providing paediatric care, to determine the OFT methods recommended by hospital staff for use at home, to establish the level of support for the idea of one national policy for OFT and to determine what senior academic paediatricians think about these issues. We conducted structured telephonic interviews of professional staff in charge of paediatric wards in 159 randomly selected hospitals providing general inpatient care. The hospitals were stratified as private, provincial and 'homeland'. We also interviewed the directors-general or the secretaries or their deputies in each ministry of health as well as directors of hospital services or their deputies in each one of the four provinces of the Republic. Lastly, we spoke to the academic heads of paediatric departments in each of the country's eight medical schools. The results show that the use of OFT for inpatient care of diarrhoeal disease is far from universal, and that the picture with regard to promotion of home OFT is even less favourable. We identified an unacceptable diversity in the OFT methods being promoted as well as a degree of resistance to the development of one national policy. We recommend that one policy, based on the recommendations of the South African Paediatric Association, be adopted by all health authorities in South Africa as a matter of urgency.(ABSTRACT TRUNCATED AT 250 WORDS)

The vaccine cold-chain is a fundamental component of any immunisation programme. This study used chemical-based temperature indicators to monitor the cold-chain constantly in the Elim Hospital health ward of Gazankulu. It was found that the cold-chain was adequately maintained at the hospital, but that as vaccine travelled towards the periphery severe breaks in the cold-chain occurred. Eighteen per cent of vaccines at the Elim Hospital store and up to 90% at the periphery were potentially exposed to temperatures high enough and for a sufficient length of time to have affected their potency. More emphasis needs to be placed on maintaining the cold-chain if we are to reach to EPI's goal of immunisation for all children by the year 1990.

The incidence of 5 of the 6 EPI target diseases, diphtheria, tetanus, poliomyelitis, measles and tuberculosis, in South Africa is examined. Incidence is linked to vaccination coverage and an assessment of municipal vaccination coverage and programme monitoring is made. Diphtheria incidence has decreased sharply and this is probably due to vaccination. A change in the cyclical pattern of polio incidence may be due to improved vaccination. No influence of vaccination could be detected with respect to measles, tetanus and tuberculosis. Vaccination programmes report results as 'total doses given' and not as coverage rates. Improvements in three major areas, i.e. vaccination coverage, programme monitoring and evaluation and programme co-ordination are proposed.

Following the outbreak of poliomyelitis in Gazankulu in 1982, the immunisation services in Gazankulu were thoroughly examined. As a result of this, a comprehensive immunisation policy for Gazankulu was accepted in November 1986. The broad aim of the policy is to provide effective immunisation to all Gazankulu residents against tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles. A specific objective is that by the end of 1987, 85% of under-5s should have been vaccinated against these six diseases and by the end of 1990 this percentage should be 97%. The detailed strategies to reach these objectives are highlighted. Within the framework of the objectives, the policy allows different areas to formulate individual strategies. Programme monitoring and community involvement are two crucial aspects of the policy and these are discussed in detail. The early successes and difficulities in implementing this policy are discussed.

A survey was undertaken to isolate the social factors which might influence the coverage rate of the existing measles vaccination programme. Although vaccinations have been carried out for several years, no decrease in the measles admission rate has been observed at Elim Hospital in Gazankulu, Transvaal. It was found that measles is still a common disease and that it is considered essential for the normal development of a child. In the treatment of measles a variety of indigenous medications are used, some of which are potentially dangerous. Almost 80% of mothers will visit a clinic if their children have measles, and 64% combine this with traditional therapy. The majority were in favour of a vaccination programme. The content of a health education programme must be carefully considered, in order to prevent adverse effects upon the population.

In this, the first of a three-part series of articles in which we propose steps towards a comprehensive strategy for the control of HIV infection, we consider briefly the world-wide experience with the HIV epidemic. Our objective is to highlight the problems and controversial issues which are pertinent to strategies for the control of HIV infection. We focus on problems of case-definition, differences between 'African' and 'Western' AIDS and the implications for South Africa, and problems with sensitivity and specificity of tests used at present, particularly in the context of false positivity in a community with a low prevalence of HIV infection. We consider some of the ethical issues, including the need for adequate counselling, the need for informed consent before testing, and the centrality of confidentiality, particularly in the context of possible victimisation and neglect of HIV-positive individuals. Differences between 'notification' and 'reporting' are emphasised. Recommendations are made regarding these problems.

In this, the third of a three-part series of articles in which we emphasise the urgent need for and propose steps towards a comprehensive strategy for the control of HIV infection, we highlight the fundamental importance of an education campaign and the three critical essentials for a successful campaign. The first concerns the responsibility of the State in administering the programme, in providing adequate funds on an on-going basis and in delegating responsibility for the day-to-day activities to the appropriate local authorities and non-governmental organisations. The second relates to the need to establish a multidisciplinary AIDS group representative of groups at risk and of relevant scientific expertise to ensure that appropriate policies are developed and that changes to policy are made in response to changing circumstances, based on sound epidemiological, managerial and educational principles. These must take particular account of circumstances peculiar to South Africa, such as the migrant labour system, which may promote both promiscuity and homosexuality. Thirdly, the need to ensure open, appropriate communication with the groups at risk and the public at large in the development, implementation and evaluation of the education campaign is emphasised. In this context we plead for more psychosocial research. These recommendations were reached largely by consensus, although there were occasions when individual authors condoned recommendations with which they did not personally agree.

A random cluster sample survey of 432 adults aged 21-60 years was undertaken to increase available information on the nutritional status of the inhabitants of northern Gazankulu and to discover the prevalence and distribution of hypertension. Mainly owing to the migrant labour system, only 9,3% of the people in the sample were men. The present nutritional status of adults is adequate by anthropometric standards. The absence of a secular trend towards increased adult stature indicates that no major improvement in nutrition and socio-economic conditions has occurred in the last 20-60 years. Mean blood pressures were found to increase with age, but the prevalence of hypertension is low compared to urban populations.

Using the random cluster sampling technique of the EPI, 210 children of 12-23 months were selected and their vaccination records were examined. Fifty-one (24%) had no vaccination record and 32 of them (15%) were never vaccinated. Using a 'worst' and 'best' estimate analysis it was found that 74-83% had had BCG, 47-56% had had 3 doses of DPT, 48-57% had had 3 doses of polio and 47-56% had had 1 dose of measles vaccine. Between 28-31% of those who received a first dose of DPT or polio vaccine did not receive a third dose. This 'drop-out' effect increased with increasing distance between children's homes and the nearest clinic, as did vaccination coverage in general. As a result of this study, several measures will be undertaken to improve health care delivery in this area. These include the organisation of a mass immunisation campaign later this year, the initiation of more mobile clinics and the training of community health workers.

An immunisation programme in a rural area of southern Africa is analysed. The combination of fixed and mobile immunisation points is discussed with reference to staffing levels, patient convenience, vaccine handling, costs and efficiency. A system of community involvement in the programme is assessed. Mobile immunisation teams to complement fixed clinic services, and active community involvement are suggested for immunisation programmes in rural areas.