PREVENTIVE SELF-CARE IN THREE FREE STATE COMMUNITIES

(b) The cost crisis experienced by all formal health care systems. On the side of the consumer, costs may be curtailed by reducing both the demand and the need for professional health care. Seemingly, the demand for carc may be scaled down by increasing the financial costs to the consumer (Abcl-Smilh 1980:26; Maynard 1986:1164) and by developing the self-care skills of patients (Levin ct al. 1977:26; Williamson & Danahcr 1978:73). The need for carc may be reduced by creating "healthier" populations in this sclf-carc in the form of prevention, health maintenance ^H ind healthier li fe styles may also play a role ^ ^ L c v in c ta l. 1977:31; Mechanic 1975:242).

(b) The cost crisis experienced by all formal health care systems.On the side of the consum er, costs may be curtailed by reducing both the demand and the need for professional health care.Seemingly, the demand for carc may be scaled down by in creasin g the financial costs to the consumer (Abcl-Smilh 1980:26;Maynard 1986Maynard :1164) ) and by developing the self-care skills of patients (Levin ct al. 1977:26;Williamson & Danahcr 1978:73).The need for carc may be reduced by creating "healthier" populations -in this sclf-carc in the form of prevention, health maintenance ^H in d healthier li fe styles may also play a role ^^L c v in c ta l. 1977:31;Mechanic 1975:242).
Outside the professional and policy sector, dissatisfaction with various characteristics of the professional care system focused additional attention on self-care as a potential contributor in health carc.Criticism of formal health care centered on the following:-* Limited effectiveness and appropriateness of form al carc, especially due to its clinical/biom edical orientation.Care furthermore tends to be fragmentary and episodic, rather than comprehensive and continuous (Dean 1986:275;Juffermans 1983:225;Katz & Ixvin 1980:330;Levin 1976:70).
With renewed interest in self-care, efforts were made to provide relevant findings for South Africa on the extent of self-care practices.Despite studies already published, existing knowledge of self-care is regarded still as fragmentary and unsatisfactory and particularly so in South Africa.
It is emphasized that a descriptive dale base on self-care is required (Dean 1981:686).Such a d ata b ase is a b o v e all e sse n tia l when governm ents have made policy decisions regarding the promotion of self-care.This is the case in South Africa, as evidenced by the pronouncement of the Minister of Health and Population Development on 14 May 1990: "'1110 health service should be preventive and prom otive and stim ulate sclf-carc in the community, which has to take responsibility for its own health."As part of a broader project of (he IISKC on affordable social security, a study was consequently undertaken during 1989 to establish the nature and extent of existing s c lf-c a r c p a tte rn s in th re e F ree S tate com m unities (Van Zyl-Schalckamp 1990).
(The complete research report on sclf-carc is available from the IISRC).

SUBJECTS ANI) METHODS
A questionnaire was designed and administered to three multi-phase random eluster samples of respondents

Health protective activities
In response to the question about the most important action that respondents take to protect their health, a healthy diet w as em p h asized by all th ree g ro u p s, w hile sufficient rest was stressed expecially by the coloured respondents as shown in Table 1.
The category healthy/clean living included responses such as the following: fresh air, warm clothes and hygiene.
Incidentally, the black group reported the highest extent of medicine use during the two weeks preceding the interview , w hich is

Regular physical, dental and cervical (Pap) examinations
The responses regarding routine medical, d e n ta l an d c e rv ic a l e x a m in a tio n s arc presented in Tabic 2.
Q uite a b ig proportion o f the coloured responden ts reported undergoing regular physical ex am in atio n s, d u e to th e widespread availability of clinic and school clinic facilities in the coloured residential a re a .R e la tiv e to p o p u la tio n siz e the coloured population is b etter served by clinics than blacks and this was commented on during the in-dcpth interviews.Both in the black and w hite groups regular physical examinations were found to be associated with perceived poor family health, and in the black group a high family income was found to be positively associated with regular physical examinations.
T h e b ig g e s t e x te n t o f regular dental examinations w as re p o rte d by the w hite respondents.In all three groups regular dental checks were associated with high levels of education and health knowledge, as well as with high family income and the availability of medical insurance.The differential availability of medical i nsurancc was marked by the fact that 95% of the white, 27% of the coloured but only 12% of the black respondents claimed to have medical insurance.
The extent of reported regular cervical (Pap) tests was distressingly low, especially among the black respondents.Two remarks regarding this arc pertinent:-(1) Due to the sensitivity of the topic and cultural taboos, black women may have been unwilling to discuss this subject with young, generally male interviewers; (2) During the in-dcpth interviews it was alleged that cervical smears arc mostly carried out on females who visit family planning clinics and often only on those women who use IUDs.In both the white and black groups, regular Pap tests were strongly associated with a high level

The inclusion or avoidance of certain types of food in the diet.
The highest extent of food inclusion as well as food avoidance was reported by the while respondents; 75,8% o f those respondents indicated that they tried to includcspecific foods in the diet, especially vegetables, protein and fibrous food.The most important motivation given was the perceived need for a healthy or balanced diet.Efforts at specific food inclusion occurred especially among those with higher levels of education and health knowledge, and with the lowest frequency among the youngest and oldest age groups.Food avoidance, especially of foods containing cholesterol, fat or oil, was reported by 43,6% of the white respondents, largely due to health concerns.Apart from high education and good health knowledge, food avoidancc in this group was also associated with high perccived family morbidity.
percent of the black respondents reported efforts at specific food inclusion, mainly vegetables and protci n, for purposes of a healthy or balanced diet.In both the black and coloured groups, food inclusion was associated with high levels of education and health knowledge, but showed a decrease with increasing age.About a third of respondents in the black group indicated avoidance of certain foods in the family diet; oily or fatty foods, owing to health ITie coloured group presented the lowest levels of both specific food inclusion (44,5%) and avoidancc (20,4%) and followed the same patterns as in the black group.

Immunization
Q u e stio n s ab o u t im m u n iza tio n ag a in st poliomyelitis, diphtheria, whooping cough, tetanus, measles and tuberculosis produced disturbing figures for the black population.Table 3 presents the responses received regarding some components of immunisation.
The respondents in the in-depth interview attributed the low reported im m unization figures in the black community to an earlier resistance to imm unization.In addition, large-scale immunization campaigns arc a fairly recent phenomenon, which implies that older people often have not been reached.The high incidcncc of tuberculosis among blacks has probably provided for a better immunization coverage for this condition.Among the black respondents a high "do not know" response was cncountcrcd, which is in itself significant.No associations were found between variables such as education, income or immunization in any of the three groups.

Exercise
The three groups differed regarding the most common types of exercise reported as shown in F igure 1.The w hites clearly can avail themselves of more varied types of exercise, while the black group performs more physical labour than do members of the other two groups.In comparison with the whites and urban c o lo u re d s in South A frica w ho have a bio-medical approach to health and disease, the black group, to a large extent, has an unique view of health, which is seen as expression of a cosmic equilibrium; serious illness may be ascribed to an imbalance of cosmic powers (Manganyi 1974:922).Regarding disease causation, black South Africans distinguish between diseases with natural or clear causes, and diseases which can only be explained by magic (Murdock 1980:8;Prctorius 1990:104;Read 1966:24).'ITic particular theory of disease causation determ in es its treatm ent -by implication this includes self-care activities, bo th p re v e n tiv e and th e ra p e u tic .The differences in the preventive self-care practices of the three groups identified in this study obviously can not be only ascribed to cultural differences, but it will be short-sighted to neglect cultural factors in efforts to develop self-care skills.

DISCUSSION
Furthermore, a uniform self-care development programme for al I groups will not be viable, due to differences regarding educational, income, health know ledge and m orbidity levels, morbidity patterns, and important sources of inform ation regarding health, disease and m edicines.Very im portant too, are the inequalities in the availability and accessibility of formal health care to the different population groups.Not only the contents of self-care development programmes will have to be g ro u p -sp ecific, but also the m ethods of education.The results of the study show that the mass media would be very effective for the black community, interpersonal sources of information in the coloured community, while medical sources and the mass media are most relevant for the white community.However, care should be taken that differential self-care development programmes do not perpetuate or even enhance current structural inequalities in health care provision.

*
The p o te n tia lly harm ful sid c -c ffc c ts associated with the professional care-giving p ro c e ss, e.g .u n n e c e s s a ry su rg e ry ,

FINDINGS
The different form s o f prevention/health m aintenance studied, w ere (1) the m ost important activities undertaken by respondents to protea their health; (2) regular physical, d e n ta l and c e rv ic a l (P a p a n ic o la o u ) examinations: (3) the inclusion or avoidance of c e rta in ty p e s o f fo o d in th e d ie t; (4 ) immunization and (5) exercise.
FIGURE 1The most important type of exercise for whites, blacks and coloureds, in percentages

2 Routine Medical and Dental Examinations and Cervical (PAP) smears for whites, blacks and coloureds, in percentages
: (1) 149 w hite households in Bloemfontein; (2) 150 black households in Mangaung (the black township adjacent to B lo e m fo n te in ); an d (3 ) 137 c o lo u re d households in Hcidcdal (the coloured township adjacent to Bloemfontein).A total of 45 interviewers, mostly students, were recruited to TA BLE 1 Only the responses of females under 55 years of age were taken into consideration.