VILLAGE HEALTH WORKERS: FIRST LINE OF CONTACT IN THE REPUBLIC OF CISKEI

Dorpsgesondheidswerkers word met welslae in die Republiek van Ciskei as eerste punt van kontak vir gesondheidsdienste ge­ bruik. Eers was ’n addisionele 3-maande kursus vir ingeskrewe verpleegkundiges, wat pas hulle kurus voltooi het, aangebied. Nou word persone uit die gemeenskappe geneem en, volgens die regulasies van die SARV, as verpleegassistente opgelei. Na die opleiding keer hulle terug na hulle dorpe om gesondheidsprobleme te identifiseer asook om gesondheidsvoorligting, verwysings, en opvolgwerk te doen. Daar word ook van hulle verwag om ’n plaaslike gesondheidskomitee daar te stel. Hierdie gesondheidswerkers word gereeld opgevolg en spesiale maandelikse opdragte, soos byvoorbeeld om algemene veltoestande op te spoor of om alle voorskoolse kinders in hulle dorp te weeg, is baie geslaagd. Aanvanklike navorsing toon dat hierdie persone ’n effektiewe bydrae tot die voorkoming en vroeë opsporing van siekte lewer.


INTRODUCTION
The h ealth care of th e m ajority of the in habitants o f South A frica's rural areas has given cause for con cern for a long tim e. T here are a num ber of suggested reasons for this.
First o f all, the burden o f illhealth seem s to be heaviest in the rural areas.T h ere are few statistics th at show this accurately but two recent surveys of infant m ortality in rural areas show ed rates as high as 198 p er 1 000 (S huenyane, 1984) and 282 p er 1 000 (K nutsen and B ow ne, 1977).This m ay be com p ared w ith infant m ortalities rang ing from 10 to 60 p er 1 000 (S utter, 1984) in th e u rb an population.T he high m ortality rates at an early age in the rural areas are m ainly related to u n d ern u tritio n and infectious diseases.
Secondly, th e rural areas have fewer doctors and th eir num ber seem s to be decreasing (the ratio of doctors to population in urb an areas in 1975 was 1:875 com pared with 1:12 700 in rural areas.By 1981 this ratio had changed to Professor Cecil Rautenbach, Head: Department of Health Sciences, Uni versity of Fort Hare. 1 : 1 2 0 0 for the u rb a n areas and 1:17500 for rural areas.(D ept of H ealth Statistics).R u ral areas also have fewer hospital beds for their population and th e overall expendi ture on health services in the rural areas is very lim ited.

TH E H EA LTH M A N P O W ER PYRAMID
A t the present tim e th ere is a very definite m edical pyram id th at exists in the recognised First W orld.This pyram id is rigidly ad h eared to and has rigidly delineated levels that places the com m unity at th e bottom of the stack (P aper, 1984) (See figure 1 ).
Because there are enough m edi cal practitioners to give th e necess ary care and to allow for rigid in ter sections betw een m edical team m em bers the above pyram id is ac cepted.
In areas w here there are not enough medical practitioners the pyramid cannot succeed.In this case the only way that successful m edical care can be given is by m eans of team work with the pyram id still in use but where the people come first.(Paper, 1984) (See figure 2).
The result of this is th at the em phasis is placed on the com m unity and because the com m unity is in volved the shift is away from cura tive to preventive m edicine.
The above com m ent raises a num ber of problem s and these can best be sum m arised as in outline 1 (Paper, 1984).

Figure 1 T H E T Y P IC A L M EDICAL PYRAMID
The

Training
Village health w orkers were used successfully in m any parts of the world.In 1980 the first sixteen en rolled nurses w ere given a special course of th ree m o n th 's duration from the tim e they finished their exam inations until they received their results.T hey were trained to be village health w orkers.

Figure 2 TH E PYRAMID A S IT SH O U LD BE
The doctor is on tap (not on top) The community health worker assumes the lead role in the health team.
OUTLINE 1 We say prevention is more important than cure -but where should prevention begin?T T T he course co ntent is given below.
• Child w elfare w ith special em phasis on: -supervision of grow th -recognising th e at risk child -organisation of a baby-clinic -treatm en t of: com m on skin diseases d iarrhoea w orm infestation.
• N utrition with special em phasis on: -p rom otion of breastfeeding -introduction of solids -nutrition education • A n te-n atal and post-natal care with special em phasis on the follow-up of hom e deliveries and th e d etectio n of n eon atal com pli cations.
• H om e visiting L ectures w ere also given on the following topics: dental hygiene, psychiatry, follow -up of chronic m edical cases, p eo p le in need of a social w o rk er, dry land gardening.
D uring th e course th e em phasis was not so m uch on theoretical know ledge b u t attaining practical skills.A fte r com pletion of the course, ten o f the sixteen candi dates w ere statio n ed in nine differ ent villages in the P eddie D istrict.T he villages w ere chosen in con junction w ith th e local M em ber of P arliam ent and rep resen ted all the tribal au thorities.T he com m unity provided accom m odation for the nurse.

Functions
T he nurse co n cen trated at first on the functions given below.

System atic home visits in their village
• Identification of health problem s and -giving ap p ro p riate health educa tion -doing follow-up visits to see p ro gress -referring to specialist services (such as the psychiatric nurse, social w orker) • M otivating people to m ake use of existing m edical services, includ ing the child w elfare clinic, an te natal clinic, family planning.

Attending clinics
A ttending local child welfare and ante-natal clinics weekly in order to identify problem cases that need hom e visits, for exam ple m alnour ished children and visits to ante natal cases.T hese nurses w ere visi ted weekly by a m obile clinic which served as a referral centre.

Health Committee
To establish a local H ealth C om m it tee and arrange regular meetings.
Special em phasis was placed on the nurses' role as nutrition educa tors, th at is: th e prom otion of breastfeeding and balanced diets as well as the follow -up of m alnour ished children.A n o th e r im portant function was the hom e m anagem ent of diarrhoea and to m ake oral re hydration readily available.

Follow-up
A m onthly feed-back m eeting at the hospital kept contact w ith these nurses.A fter several m onths the following facts becam e clear: -the attendance at the m obile clinic in the villages w here these nurses w orked rose sharply, es pecially for the under-five clinic -these nurses w ere very good at recognising pathetic social cases in need of urgent atten tio n and these could be referred to the social w orker -the im portance o f close supervi sion of the w ork o f these nurses becam e very clear.A registered nurse was appointed as super visor and to organise future courses.Lack of transport m ade proper supervision difficult -people often asked the nurses for m edicines.This em phasised again the fact th at preventive and prom otive m edicine w ithout curative m edicines is not very well accepted.A s a result of this, the nurses w ere allowed to keep a lim ited am ount of m edi cines to be issued as one dose only.These included mainly simple derm atological p re parations, pain tablets and oral rehydration pow der.T he nurses were also allowed to do daily dressings of surgical wounds mainly on patients referred from the hospital -after the nurses finished the first round of hom e visits, they becam e discouraged by not seeing any im m ediate results.
O n follow-up hom e visits they still did not see any results.This affected their m otivation and som e lost interest.
A fter the initial course a num ber of new procedures w ere introduced to m ake the nurses' w ork m ore in te resting.
-A hom e visit card was in tro duced.This card is com pleted for every household and is filed by each nurse.N otes on followup visits are attached to these cards.This also helps supervi sors to get an idea o f the num ber of households and the num ber of inhabitants of each village.-The nurses were allowed to treat tuberculosis patients as o u t p a t i e n t s o n a d a i l y b a s i s .
Patients on the 120-day regim e (including R ifadin) w ere care fully selected at hospital level to m ake sure th at they stay within easy walking distance from the nurse.The patients take their treatm ent daily from the nurse and she is in a position to trace the patients im m ediately if they do not attend.She can also trace contacts at the p atien t's hom e.
-A t each m onthly m eeting a health topic was decided on.
The nurses then talk to the H ealth C om m ittee m em bers who in turn spread the inform a tion to the com m unity.This was introduced to keep the m em bers of the H ealth C om m ittees m oti vated.
-A week-long refresher course for the nurses was organised.

Second course
In June 1981 the second course started with sixteen candidates.T en candidates passed their exam in ations and these w ere then all a t tached to p erm anent clinics for two reasons: -it becam e ap p aren t that these nurses could be used in com m u n itie s a r o u n d p e r m a n e n t clinics as well -supervision is easier, especially where there is no m obile clinic to visit them regularly.
A t this stage a m ajor problem arose -it related to the selection of candidates.U p to this point only enrolled nurses who had com pleted their training had been used.It soon becam e ap paren t that som e candidates w ere not well m otivated for their work.A ttending the course and being em ployed in this way m eant continuous em ploym ent for some of the nurses.Previously they often had to wait for a p erm a nent post for a long tim e after quali fying.

Nursing Assistants
A fter consideration of the problem s the whole project was rethought and the following changes w ere made: -in future enrolled nursing assis tants instead of enrolled nurses would be trained as village health w orkers -the candidates w ould be se lected by their own com m unity -the m inim um educational re quirem ents would be Std 5 -they would be trained for six m onths, enrol as nursing assis tants with the Nursing Council and then return to their own vil lages.
The six-m onths' training was div ided into two parts, a tw o-m onths theoretical and a tw o-m onths prac tical part.The theoretical part cor responded with the course given to the enrolled nurses.T he new candi dates, how ever, had no nursing background, and also had low edu cational qualifications.T he course had to comply with the req u ire m ents laid down for enrolled nurs ing assistants by the Nursing C oun cil.T herefore lectures on nursing ethics, basic anatom y and physi ology as well as first aid w ere in cluded.
D uring the practical part trainees were divided into small groups and spent two-week periods in the fol lowing departm ents: -m aternity -paediatric outpatients -fam ily p la n n in g /p s y c h ia tric clinic -nutrition rehabilitation centre -m obile clinic -tuberculosis treatm ent -perm anent clinic -stay with a village health worker.
On com pleting their training these trainees were enrolled as nursing assistants and then retu rn ed to their villages as village health workers.
A t present the use of the village health w orkers is continuing.T heir role and function is being m oni tored closely.

Assignm ents
M eetings are held m onthly on the day that the doctor visits a particu lar clinic.Each w orker then reports his or her activities during the past m onth, a lecture and/or d em onstra tion by the doctor follows and fi nally a practical assignm ent for the coming m onth is set.

Lectures have included:
-im m unisation -breastfeeding -weaning and principles of n utri tion -use of Child H ealth C ard, in cluding plotting of weight on the graph -com m on skin conditions -spread of infectious diseases -tuberculosis -gastro-enteritis -oral rehydration therapy -prevention and m anagem ent of burns -high blood pressure -epilepsy -cholera.Some of the assignm ents have been very effective.T he following are a few examples.
Checking immunisation status of all babies and pre-school children and referral to clinics where applic able.In one area this led to the re ferral in one m onth of 305 children who required som e im m unisation but were not attending clinic and the detection of five new cases of active tuberculosis.A lthough a new assignm ent is set each m o n th , w ork ers are expected to apply th eir accu m ulated knowledge at all tim es and in the case of im m unisation surveil lance, this has been especially useful in ensuring th at children are being protected against tuberculosis and measles.
Weighing of pre-school children in each village.M any children are already enjoying nutritional surveil lance and advice if they stray from the R oad to Health chart.W orkers are becom ing proficient in the use of this chart and are able to in ter pret it intelligently.Detection of common skin diseases.During one month, workers carried out a cam paign to detect com m on skin diseases such as sca bies, im petigo, ringworms and nappy rash.T hey called m eetings in their villages and discussed the causes and p revention of these diseases.H u n d red s of children were referred to th e clinics for m an agem ent.
W orkers are expected to call reg ular m eetings to discuss the topic of the m onth.D iscussions and ideas are invited from th e audience.T he m eetings are o ften held in conjunc tion with th e h ead m en 's m eetings.
T he w hole schem e appears to be gaining th e su p p o rt, co-operation and respect o f th e com m unity and headm en, in a m ost gratifying way.
A n overw helm ing num ber of patients w ith chronic diseases and handicaps have been discovered and referred fo r w hatever tre a t m ent o r help is available.M any are s e rio u s s o c io -m e d ic a l p ro b le m s w here a g ran t, which is applied for, constitutes th e best therapy.
The cholera th rea t dem onstrated how effective Village H ealth W ork ers can be.T hey called m eetings in all th eir villages, dem o nstrated the use of suitable chem icals for w ater purification (household bleach) and how to build p it latrines.In one area m o re th an o ne h u n d red la trines have b een dug.
W hen p eople com plained th at they did not have m aterials and m oney to erect enclosures for their latrines, one village health w orker suggested th a t th ey use the soil they had dug o u t to m ake m ud bricks and use these for building the walls of the lavatories.T hey have also e n couraged p eo p le, for th eir own good, to buy th eir own bleach and not always to depend on the clinics or authorities.It is clear that they prom ote self-reliance very effec tively.
In addition to their m ore m edical activities, vegetable gardening has also been undertaken.Pig and poul try farm s are u n d er consideration.
All this has been achieved with only a few hours of lectures and as signments.

C onclusion
D r T Thom as in considering the w ork carried out by the village health w orkers m ade the following statem ent: I w ould like to subm it that it is only necessary to train sufficient health workers to ensure childhood immunisation, pro m o te breast-feeding m onitor nutrition and the R oad to H ealth C ard, recognise and act upon the causes and signs o f m alnu trition, gastro-enteritis, tuberculosis and measles, and to understand and propagate a hygienic life style fo r them to m ake a rem arkable impact on the health o f their villages.
A ll this is entirely feasible and well within the ability o f interested and well-chosen village health workers and they are in fa c t ideally placed to carry it out.There can be no pre tence that the present health service is reaching all the people it is meant to serve.Nurses are necessarily clinic-bound because o f the shortage o f sta ff and are overburdened with curative and adm inistrative work.
They have no transport so that any outgoing w ork is necessarily m ini mal.These considerations apply with special emphasis on the rural areas where staff/patient ratio is p a r ticularly unfavourable and where clinics serve huge areas with scat tered communities.(Thom as 1984).
The developm ent of a netw ork of well trained village health w orkers provides an excellent first line of defence in health care.A t the pres ent m om ent the biggest stum bling block is the question of rem u n era tion of the village health workers.This question is receiving attention and a num ber of m ethods are being considered but as yet no answer has been found.
Ongoing research is being carried out on the effectiveness of the vil lage health w orkers.Prelim inary re search results have indicated that these people are an effective first line of health defence and their task, as well as effectiveness, will be closely m onitored.13) is.D it is nog baie na aan die onterapeutiese punt w at op o n d er 1 0 punte gestel word.D it is belangrik om nie die doelw itte ten opsigte van inter persoonlike vaardighede vir stu dentverpleegkundiges te hoog te stel nie.D it sou onrealisties wees as die ontw ikkelingstadium van die student self en die ingew ikkeldheid van die taak in aanm erking geneem word.

Following
up special ca se s -M alnourished children, th at is: below 3rd centile o r no weight gain for th ree m onths o r m ore.-Post-natal care of hom e d e liveries o r deliveries discharged from hospital or clinic.-Tuberculosis contacts o r d e faulters.-C hronic cases, such as patients with epilepsy, diabetes and hy pertension.-Psychiatric cases.-Fam ily planning clients.

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A register for m alnourished c h i l d r e n w a s i n t r o d u c e d .W eekly weights o f m alnour ished children are plotted on a graph and the nurses are en couraged to visit these children frequently, even daily if necess ary.This becam e a m ajor task as some nurses have up to twenty m alnourished children to visit.-A n a tte n d a n c e r e g is te r fo r patients suffering from chronic medical conditions was intro d u c e d .N o n -a tte n d e r s co u ld then be visited at hom e.

(
Vervolg vanaf p 19) speel.H ierd ie tip e opleiding kan dus m et vrug in die program m e van studentverpleegkundiges ingesluit word.D it w ord v erd er w eer eens duidelik hoe belangrik dit is om die effektiw iteit van leerg eleenth ede te evalueer.B aie dosent-en studente-ure gaan verlore in oneffektiew e leerge leenthede.> Schlofeldt en M ethven se em patie-skaal tel uit dertig.D it is opm erklik d at, n a tw ee sem esters van redelik intensiew e opleiding op hierdie gebied, die groep se gem id deld steeds m aar d ertien (