Why Not a Nurse Demographer?

Die skrywer glo dat opnames onder hoërskoolleerlinge waardevoUe demo-grafiese inligting kan voorsien. Die uit-voerbaarheid hiervan is in die veld ge-toets. In die bespreking van die bevindings stel die skrywer 'n stelsel vir die regi-strasie van geboortes en sterftes in nasio-nale state voor waarin die gemeen-skapsverpleegkundige en piaaslikc kliniek gebruik word. Watter wyse van registra-sie ook op besluit word kan dit koste-ef-fektief evalueer word deur roetine op-names by hoërskole vir noodsaaklike de-mografiese inligting. Dit word voorgestel dat die verpleeg-kundige-demograaf die betroubaarheid van die gegewens in al die noodsaaklike geboorte, mortaliteits-en morbiditeits-koerse kan verseker.


INTRODUCTION
Populations of school children can be utilised for th e screening of illhealth such as ophthalm ic (K ohler et al, 1981: 369-77) and aural (Me D erm o tt, 1982: 462-8) conditions, h eart disease (O k u ni, 1982: 1250-4), scoliosis (L onstein et al, 1982: 481-8) or dental caries (R ebich et al, 1982: 50-53), with th e sole object of clinical intervention.T he target p o pulation is aim ed at all belonging to a defined risk g roup, usually d e scribed in term s of age, sex, eth nicity and occupation.
W hereas screening is an ongoing process, surveys are isolated exer cises directed at w ider populations in o rd er to d etect th e m agnitude of a problem with th e long-term objec tive of planning o r screening.In ter vention does not accom pany sur veys.Such surveys are essential for health planning and usually denote the point prevalence o f chronic problem s such as trachom a (B allard et al, 1979: 113-120), dental caries (W H O , 1977), m alnutrition (Leary, 1969(Leary, : 1170-74)-74), intestinal helm in thic infestations (S chutte et al, 1981: 137-41), bilharzia (V isser, 1984: 124-27), school girl pregnancies (Craig, 1983: 452-55) and tubercu losis (F ourie, 1981).Screening tests and surveys have also been em ployed by the D e Lange report in com piling a blue print for school health services in South Africa (R aad vir G eestesw etenskaplike N avorsing, 1981).
In dem ographically young p o p u lations, such as th at of South A fri can Blacks (C entral Statistical Ser vices, 1980: 1-4), a very large p ro portion of households will contain schoolgoing children (Jean n eret, 1976: 101-7).T he high school group should be able to furnish valuable dem ographic inform ation such as recent births o r deaths and the prevalence of existing disability or chronic illness.
If this inform ation w ere gathered at the beginning of each year as an ongoing screening procedure, the com m unity health nurse could visit the positive replies to ascertain w hether the births and deaths had C U R A T IO N IS actually been registered o r w hether disabilities and chronic illnesses w ere receiving attention.In this way tedious door-to-door active surveillance could be reduced or elim inated.Turning the above prem ises into a hypothesis it was decided to test its feasibility under actual field conditions.

POPULATION AND METHOD
The largest high schools in each of the two Black townships o f Tem bisa and K atlehong on the E ast R and w ere selected.E ach child com pleted a questionnaire u n d er the direct supervision of one of th e two nursing authors.P rior perm ission was obtained from the principal and each questionnaire was checked for om m issions im m ediately upon com pletion.It took less than 10 m inutes for m ost pupils to com plete a com p u te r o r ie n ta te d q u e s tio n n a ir e .(Sam ples are available upon re quest).
The application of th e inform a tion contained within the question naire was fully explained to each class beforehand, as well as th e fact that for survey purposes anonym ity would be guaranteed as th e ques tionnaire m ade no provision for nam e or address.B ecause of the m ethod em ployed, the retu rn for all pupils present on th at day, was 100%.
D e m o g ra p h ic p a r a m e te r s e n quired into, consisted of any deaths or births which occurred during the previous calendar year at th e house hold w here the scholar lodged, w hether it was the p aren tal hom e or not.T he presence of any cripple, spastic, m entally re ta rd ed , epilep tic, deaf or blind person in th e same household was also investigated.

RESULTS
The results are depicted in table 1. T h e c h a r a c t e r i s t i c s o f a dem ographically young population are im m ediately evident in the high frequency of both deaths (9,8% and 9% ) and births (18,1% and 15,4% ).
The frequency of epilepsy (4,8% and 4,1% ) is very high and im m edi ately identifies it as an im portant com m unity health problem .The frequency of crippleness, blindness, m ental retardation and deafness re m ained below 4% .
The presence of one o r m ore sib lings at the same school occurs fre quently (34,4% and 20,0% ), again as could be expected.The widely differing proportion of pupils with siblings at the two schools (X2 = 53,67: P < 0,05) rem ains unex plained.
School A pupils had relatively m ore blind people at their place of residence (P < 0 ,0 5 ) and school B m ore m entally retarded persons (P < 0,05) respectively.These differ ences are purely statistical, how ever, and may be well within the norm al range of biological vari ation.
Births, deaths, epilepsy, cripple ness and deafness seem to occur with the same frequency at both schools (P < 0,05).

DISCUSSION
The reliability (repeatibility) of the survey will be partly indicated by the similarities and differences in results obtained from the two schools, as already discussed.A l though it is difficult to prove, the authors feel that w here differences do occur, they are due to true vari ations in the two populations rather than to m ethodological erro r.
Validity (specificity), will be re flected in the num ber of false posi tives.As no likely m otive can be ad vanced as to w hat benefit would accrue to a pupil if he m ade a false positive report, specificity can be considered to be n ea r absolute.Once positive replies are followed up, false positives will in any case becom e apparent im m ediately.
Validity (sensitivity), how ever, may prove to be a real problem as, for exam ple, political m otives may exert pressure on a scholar to withold inform ation.As the num ber of false negatives can only be ascer tained by door-to-door surveys, which is exactly w hat one tries to avoid, it seems m ore sensible to counter it through b etter health education and by dem onstrating that follow-up is for the benefit of the sick o r new born, and never for legal sanction.
A nother strategy which can be followed is to com pare the replies of siblings with each o th er for con sistency.It was n o t done in this series because of th e strict criteria m aintained for the reservation of anonymity.F or fu rth er inform ation on the execution and in terp retatio n of health surveys the excellent w ork o f A bram son may be consulted (A bram son, 1979).
The figures of the survey and the national census can of course not be com pared as the school children do not constitute a representative sample of the com m unity and also because for each additional sibling the sam e inform ation is duplicated.The present state of affairs is clearly unsatisfactory and it seems logical to register births and deaths in the national states under health legislation only, for the reasons given below.
• The D epartm ent of H ealth and W elfare, which deals directly with the act of birth or death, will effect registration.
• The nurse, rather than a policem an or other official, is m ore capable of ascertaining the cause of a natural death.P re sently a large proportion of deaths is attributed to unknown causes (W yndham , 1981: 411-9).
• Clinics in the national states are geographically better distributed than police or magisterial offices where registrations are at present effected.
• Registration of births can be coupled with the right of access to health services or schools, rather than to a penalty clause, thus introducing a positive incen tive.
• m ore accurate denom inators, available within a shorter time span, will enable authorities to calculate vital statistics m ore precisely for the purpose of plan ning and evaluation.

CONCLUSION
It is proposed that routine screening of high schools for essential dem o graphic inform ation on an annual basis, as described before, will be a cost-effective evaluation tool for w hatever form of registration is fi nally decided upon by the legis lator.This m ethod of active surveil lance can be applied in both rural and urban situations.The nurse epidem iologist has long since proven her worth.Surely the nurse dem ographer is capable of ensuring that at long last one will be able to believe the denom inators contained within all our essential natality, m ortality and m orbidity rates?
P.W.W. Coetzer, MBChB, DVG, DBG, MD, DTM&H, Senior Lec turer/Senior Specialist, Department of Community Health, University of Pretoria G.P. Menyatso, Senior Professional Nurse, Tembisa City Health Depart ment, Germiston (Died 26 July, 1982) M. Mosisidie, Senior Professional Nurse, Tembisa City Health Depart ment Births are registerable u n d er the B irths, M arriages and D eaths R e gistration A ct No. 81 of 1963, as am ended, and notifiable u n d er re gulations prom ulgated in term s of the Public Health A c t N o.36 o f 1919, as am ended (Section 133(1)).

Figure
Figure 1 Proposed diagram for the reporting of live births in the national states

Proportion of pupils in w hose household a blind person resided 22 2,1 10 0,9 Proportion of pupils in w hose household a deaf person resided 14
1,3 17 1,6