botshabelo's vaccination survey

582 SAMJ VOL 80 7 DES 1991

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STEPHANIE DE MONTIGNY, P. DE L. G. M. FERRINHO, - - , .

P. M. BARRON, R. LOZAT, J. S. S. GEAR

Summary This community-based survey evaluates vaccination coverage of small children and socioeconomic status of their house!mlds in a randomly selected sample of a black South African towm ship. It reveals a poverty-stricken community, where only 19% of the children surveyed were fully vaccinated. It is suggested that expansion of health infrastructures together with a coordi- nated strategy of immunisation would result in a spectacular increase in vaccination coverage.

S Afr Med J 1991 ; 80: 582-584.

Rapid urbanisation in South Africa has resulted in large periurban sprawls. This is a world-wide phenomenon. South Africa is unique in that resettlement policies have resulted in this urbanisation taking place far away from existing urban centres. Botshabelo, near Bloemfontein, is one such settle- ment.

Botshabelo township was created in 1979 in a farming area of the Orange Free State. Its population grew rapidly to reach what is now estimated at over half a million inhabitants, in an area of 12 000 ha. Its inhabitants are exclusively black South Africans, mainly Sesotho. Since its inception it has been threatened with incorporation in some of the surrounding homelands. Its legal status is still being debated in court.

Health services in Botshabelo are particularly underdwe- loped. The hospital, originally planned to have 500 beds, cur- rently (1989) has only a maternity ward and a paediatric ward, and a 16-bed adult emergency ward. Community health services include 5 fixed clinics and 5 mobile clinics to serve the 16 sections now occupied in Botshabelo. Immunisations are delivered on a weekly basis in these clinics. No info~mation on immunisation coverage in the area was available beyond statistics based on clinic visits. The inadequacy of information based on numbers of vaccines dispensed during visits to health centres has recently been emphasised.' It was therefore deci- ded to carry out an evaluation of vaccination coverage using data from a properly selected community sample.

This type of information is not only of regional but also of national interest, as data on health status of rapidly urbanising areas of the country are meagre. Except for a handful of reports on vaccination coverage of urban and pen-urban populations in the RSAY2-l2 very little information exists on

Mkdecins du Monde, 67 Avenue de la Republique, Paris, Frapce STEPHANIE DE MONTIGNY, MD. RLOZAT,MD. ,

Department of Community Health, University of the Witwatersrand, Alexandra Health Centre and University Clinic and Institute for Urban Primary Health Care, Johannesburg P. DE L. G. M. FER-0, M.B. CH& D.T.M .& H.,M. SC.(MED.) P. M. BARRON, M.B. CH.B., B.COMM.,F.F.C.H.(S.A.) J. S . S . GEAR, M.B. B.CH., D.T.M. &H., D.P.H., F.C.P. (S.A.),D. PHIL. (OXON.)

Reprint requests to: Dr S. de Montigny, Senice de Gastro-enrkdogie, H6pital Hatel. Dieu, 1 Place du P& Name Dame, 75004 Paris, France. Accepted 13 Sep 1990.

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which to base plans for child health care delivery to these pop ulations.

In order to help a section of the Botshabelo community to collect information essential for better demand for community-based services, Mkdecins du Monde, Alexandra Health Centre and the Depamnent of Community Health of the University of the ~Lwatersrand supported a-community sur- yev to collect socio-economic information. data on vaccination status of small children and information on attendance at maternity care services.

Methodology

The study was a cross-sectional analytic study of sections A, B, D, E, L, M, N, and T of Botshabelo. These were selected as being the most disadvantaged sectors of the community and because Mkdecins du Monde had close contact with community members in th&e areas. The total number of plots of the areas studied amounted to 19 46 1.

The studied group consisted of 100 children b.etween 12 and 23 months of age. One hundred households were ran- d o m selected kom a list of all the households in the area. Each household has a unique identification number. The child in the correct age group living in the selected household was ' included in the survey. If there was no such child the index child was sdected fkom the household nearest, in numerical sequence, to the initial one. If no one was at home, or if the mother or permanent guardian of the child-was not present, an appointment was made either through the neighbours or by leaving a note at the household. Three attempts were made to contact a particular household. Failure after the third attempt was compensated by replacement. If there was more than one child in the relevant age group the christian names were asked and the first in alphabetical order was selected.

The survey was conducted during 5 days in August 1989. Information was collected from the vaccination cards and an interview was conducted, in the vernacular, with the penna- nent guardians, by four locally trained community health workers.

Analysis was conducted using a SAS programme. Statis- tical significance was calculated using Student's t-test and the X2 test. The sample size ensures confidence intervals within + 10% of the measured proportions.

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Results ,ss

One questionnaire was excluded because of a mistake with the- child's age, and 1 interview was done on replacement because of a refusal to participate in the study.

Of all the interviewees, 37% lived in brick houses, 41% in zinc houses and 22% in mud houses.

Seventy-three per cent of the interviews were conducied on first visits, 25% on second visits and 2% on third visits. Ninety per cent of the intemiewees elecjed to be interviewed in Sesotho, 5% in Setswana, 3% in Xhosa and 2% in AfEkaans. The respondents were 20 - 29 years of age in 46% of cases; 8% were below this age and 46% above. Sixty-two per cent had lived in Botshabelo for 5 years or longer.

SAMJ VOL 80 7DEC 1991 ' 5E3

Only 2% of the household had other children in the target age group. The mother was interviewed in 75% of cases and the grandmother in 17Y$ the remaining interviews were with someone else.

Ofthe 75 mothers interviewed 68% were housewives, 27% were working and 5% were schoIars. Forty per cent were mar- ried in customary unions and 37% in civil rues, 9% had a steady boyfriend, and 13% were either single, widows or acknowledged having muitiple sexual partners. Seventy-five per cent said that they received financial support from the father of rhe child. Fifry-two per cent of the mothers had less than 6 years of schooling and only 1% had more than 10 years.

Twelve per cent of mothers had never received antenatal care while pregnant with the index child and 19% delivered at home.

When asked What do you think immunisations do for a child', 70% of inte~ewees mentioned that they prevented diseases, 7% thought they were good for the child but could not specify why, 20% did not know, and 3% thought they were harmful. Of the 70% who mentioned prevention of ill- ness, 81% mentioned measles, 48% polio, 41% tuberculosis, 28% whooping cough, 24% diphtheria and only 5% tetanus.

Vaccination cards were not available for 27% of the children (9% had never had one, 7% had lost it, and in 11% of cases the card was elsewhere). Of these 27% 58% claimed some vaccination but could not speck@ against what, and 19% claimed vaccination against tuberculosis, 15% against measles and 7% against polio.

Of the 73% of the children with a written record of vaccination, 100% had received ECG, 79% had received the first dose of vaccine against poliomyelitis, diphtheria, whooping cough and tetanus (P-D-ml), 60% had received P-DWT2, 43% had received P-DWT3 and 42% had received measles vaccine (Table I). Only 23% were fully vaccinated at the time of the i n t e ~ e w and none had been fully vaccinated by 12 months of age. If we assume that the children with no card are not fully vaccinated, then only 19% of the children surveyed were fully vaccinated.

TABLE I. NO. AND % OF CHILDREN IMMUNISED No. %

BCG 72 100 P-DWTI n 79 P-DWT2 43 60 P-DWT3 31 43 Measles 30 42

The atss at which vaccines were delivered are presented in - Table II.

TABLE II. AGE AT VACCINATION Range Mean age

BCG Birth -8 mo. 0,6 m. PDWTl 2 - 13,2 m. 4,7 m. PDWT;! 4 - 23,2 m. 916 trio.

Paw13 5 - 232 mo. 9,9 mO.

Measles 6 - 21 mo. 1 0,7 m.

When asked to desaiie the vaccination procedures 38% of the respondents were able to do so in the case of tuberculosis, 34% with measles, 200/0 with DWT and 9% with polio.

Respondents were asked W e have found that many children are not fully vaccinated. Are there any reasons that make it difficult for you to go to any of the existing vaccination stations? Sixty-nine per cent mentioned that there were no probIems, 8%mentioned poor heraction with nursing S&, and 5% said that it was too far, the rest of the sample gave other reasons. When specifically asked if the vaccination stations were too far away 88% said no and 12% said yes. Eleven per cent did not know where vaccines were admini- stered and 34% did not know the days and time of well-baby services.

For the purpose of comparative statistics two groups were defined: those fully vaccinated at the time of interview (N=19) and the rest of the sample. There were no statistically significant differences between the two p u p s concerning the age of the child at interview, section of residence in Botshabelo, presence of other under-5 children in the household, nature of the childminder, financial support from the father, maternal level of education, occurrence of antenatal care and place of delivery, or age of the mother.

Discussion Because of the ease of obtaining a simple random sample of the target population, we elected to do this rather than fol- low the standard Expanded Plan on Immunisation (EPI) meth~dology.'~ This resulted in significant cost reductions without loss of statistical power or precision.

This study reveals a reasonably stable population (62% had lived in Botshabelo for more than 5 years) with a high illiteracy rate and with a quarter of households reporting that the child's father was not providing any type of support. Most people lived h non-b~'& houses, supporting our impression thar we were dealing with a poverty-saicken communityx = - - - ..

The shocking reality is the neglect of preventive care of children m the presence of reasonable attendance at services for pregnancy care. The vaccination coverage figures are the worst ever reported fkom the RSA. A recent report from the Orange Free State reports vaccination coverage of 38% for children of farm workers.14

Childminders do not know where and when well-baby services are delivered, suggesting that the services are not prop erly advertised; nevertheless, they believe that vaccines are good and that children should receive them. The impression is therefore of a receptive group and that co-ordinated effort directed at providing adequate vaccination coverage would meet with a significant response &m the population. For this to be achieved the present level of mistrust of the official sector s e ~ c e s should be corrected. The strategy of a mass immunisation campaign, together with the expansion of infrastructures to provide properly advertised and accessible immunisation s e ~ c e s on a reguhly predictable basis, is likely to result in a spectacular increase in vaccination cove~age.~s~~ . REFERENCES

1. IJsselmuiden CB, Kimner HV, Banon PM, Steinberg WJ. Notifidon of five of the EPI fareet diseases in South Afiica. S A+ Med 7 1987; 72: 31 1 - 316.

2. Kearney M, Yach D, Van Dyk H, Fier SA. Evaluation of a mass measles immunisation campaign in a rapidly growing periurban area. S Afr MedJ 71;- 157-1 50 . -. - - . - - *.

3. Barron PM. Alexandra township - is immunisation adequate? S Afr MedJ 1987; 72: 339-340.

4. Barron PM, Feninho P de LGM, Buch E a d. Community health sunrey of Oukasie, 1987. SAfrMedg 1991; 79: 32-34.

5. Rees H, Buch E, Ferrinho P de LGM, Groeneveld HT, Neethling A. b & o n coverage and reasons associated with non-immunisation in Alexandra township in September 1988. S Afr Med J l991 (in press).

6. Wagsrafff, Yach D, Mkhasibe C. Study of faftors assodated with dehy- drating diarrhoea in Soweto children. S Afr J Epidenriol Infm 1989; 4: 71-73.

7. Yach D, Coetzee N, Hugo-Hamman CT, Fisher SA, Kibel MA. Identifying children at risk in peri-urban Cape Town. S Afr J Efnkhiol I q f h 1990; 5: 6-8.

584 SAMJ VOL 80 JDES 1991

8. Goerme N, Fisha S, Yach D, Blignam R Site C immunisation survey, Cape Town Urbrmicanbn and H& Nmsker 1989; I : (Apr), 9-1 1.

9. Depamnent of National, Health and Population Development. Immuni- sation coverage m Laudrum, Pretoria. Epidemiologid C-B 1989; 16 (8): 16-22.

10. Department of National Health and Population Development. Immuni- sation eoverage in Easrerus, Pretoria. Epibmbhgical Cammenu 1989; 16 (10): 13-20.

11. Depamnent of National Health and Population Development. Vaccination cwerage of white children in Pretoria. E m l o g i d C-B 1989; 16 (12): 11-16.

12. Padayachee GN, De Beer M. An immunisation coverage survey of a h@-

rise, high density area urilizing the Wodd Health ' ' n Expanded Programme of Immunisation Coverage Met= CHXSA 3 C+* H& 1990; k 69-72.

13. Laneshow S, Robinson D. Sunreys to measure programme coverage and impact:.a review of the methodology used by the Expanded Programme on I non. World H& Srar Q 1985; 38: 65-75.

14. Chapman RD. The Orange Free State experience - determioing both primary health care coverage and the healrh status of blacks living on farms. CHASA J Comprhenciw H& 1989; 1: 30-37.

15. Jacobs ME, K i l MA. An urban strategy towards the EPI. S A& Med 3 1987; 72: 327-328.

16. Editorial. Immunisadon. S Aji JEpi&miol I n f w 1989; 4: 2.

Reproductive health care in the Gelukspan health ward

P. DE L. G.. M. FERRINHO, J. S. S. GEAR, G. J. RElNACH .

Summary

Reproductive healih care, namely family planning, antenatal care (ANC), labour care and postnatal care, was studied in the Gelukspan health ward of Bophuthatswana in 1985 -1986.

Only a minority of the women interviewed (20%) had planned their last pregnancy, but most had attended for ANC (93%) and had had supervised deliveries in a hospital or clinic (80%). Most (97%) knew of modem methods of f e M i i control but only a minority (3796) were using them.

Planned pregnancies were more likely to be reported by mamed women (73% of 37 v. 9% of t73; P= 0,0000) who lefl school at an eaKm age (16,O _+ 5.9 years v. 17,O f 3,9 years; P = 0,0462). .If unmarried, women who had planned their pregnancy were more likely to be maintained by the father of the child (15% v. 4%; P = 0,0134). They were also kss likely to have left s c h d because of the pregnancy (20% v. 50%; P = 0,0001). Unmanied women with supervised deliveries are more likely to have financial support from the father of the child.

Maternal school education is positively related to attendance for ANC, attendance for supervised labour and utilisation of modem methods of tertili contrd.

t Them seems to be an intricate relationship between the - 4 different outcomes measured. ANC attenders were more likely

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, , k;6 to have supervised deliveries. Both groups were more likely I . a tq start attending for child health care earlier and more

.?.l !:. - % frequently. Our results are discussed.

Alexandra Health Centre and University Clinic and Department of CommuniQ Health, University of the Wit- watersrand, Johannesburg P. DE L. G. M. FERRINHO, M.B. ~ H . B . , D.T.M. & H., M.SC. (MED.) J. S. S. GEAR, BSc, M.B. B . M , D.P.H., F.CP. (S.A.X DSIiIL. (OXON ), D.T.M. & H. Institute for Biostatistics of the South African Medical Research Council, Pretoria G. J. REINACH, D.SC (AGRIC)

In developing counmes the health care of mothers is m&e neglected than that of their children.'" Reproductive heaith care, namely family planning (FP), antenatal care (ANC), care during labour and postnatal care (PNC), is an essential corn-. ponent of any primary health care (BHC)

The importance of FP is underlined by the negative impact of high fertility on the health of both mothers and ~hildren.~,~ Effective FP programmes also give women the sense that they are in control of their destinies, and a new freedom to participate in socio-economic activities.

ANC is a controversial component of PHC. A great deal has been written on both the benefitsg-" and the i ~ d e ~ u a c i e s ' ~ - ~ ~ of ANC. The controversy revolves around the issues of 'wbat care', 'how frequently', and 'for what purpose'. However, ANC remains an accepted and important component of health care, particularly if a risk approach is adoptedY18 although the difficulties of such an approach in a developing country should not be underesti~nated.~~

The need for supervision-of labour by trained midwives is unq~estioned.~~ A lot of creativity has gone into the promotion of schemes to provide supervised delivery of babies either at home, with the training of traditional midwives,2' OF, pre- ferably, in c k s and h ~ s ~ i t a l s . ~ ~ - ~ ~

In the Gelukspan health ward SGHW) of ~ o ~ h u ~ s w a g a , South Africa, maternal care has been a constant priority. Reproductive care has been provided by 8 fxed clinics.ind 11 mobile clinics, and in the hospital." Since 1986 _modern FP has also been available at all villages in the GHW through a mobile under-5 clinic." FP in the district was studied by Sutton in 1983.25 Most

women knew about modem FP methods, the majority wanted to use them, but only a minority was actually using them.25

Health service statistics suggest that attendance at &t once for ANC during any pregnancy has increased from 63% in 1980 to almost 100% in 1984. Despite this, the repeat attendance after ANC booking dropped from 5,5 in 1980 to 4, 1 in 1984.23 In 1980 distance and lack of transport were given as the most common reasons for not attending for ANC23 By 1984, however, most women had access to ANC within a ratio of 10

botshabelo's vaccination survey

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