The Use of Reproductive Health Information Material in the Rural Clinics of Umtata District

Though it appears that there has been a long history of development .distribution and dissemination of reproductive health information materials, impediments still exist ND Mbananga in the health information .communication and education systems in South Africa. M A The aim of the study was to contribute towards improvement of the deve-lopment, Medical Research Council distribution and utility of reproductive health information material both in the Eastern Cape province and nationally. In-depth understanding of complexities surrounding development, distribution and utility of educational material is key to the provision of information to communities. The objectives were to describe the availability and examine the content, target groups, language and utility of reproductive health information materials. Qualitative study using non probability sampling was done. Ten rural clinics were conveniently selected. In-depth interviews, focus groups and a checklist were used to collect data. Reproductive health information materials found were mostly posters, there were no pamphlets, material on some reproductive health aspects was not available, inconsistently distributed and not updated. It was concluded that posters are available in the rural clinics of Umtata district judging from the results there is a need to improve the quality of reproductive health information material. “Reproductive health information was barely sufficient to display at clinics, and therefore, not serving its purpose of community education.” INTRODUCTION During the 1970s South A frica established an acute Family Planning Programme within the Department of N ational Health and Population Development(PDP). This programme became a strong vertical family planning service, w hich em barked on mass provision of contraception, while also running education, inform ation and communication programmes, (Klugman 1993). Since this period, the National Department of Health together with some organisations have developed, distri­ buted and disseminated family planning information materials to communities and clinics. South African health services faced a critical review during the preand post e lection periods around 1994. The concept of sexual and reproductive health was introduced in South Africa for the first time (WHO 1994). The inclusion of both sexual and reproductive health meant redefinition of demarcation lines. This definition suggested that traditional areas, such as maternal health and family p lann ing , shou ld be broadened to include safe abortion services, cervical screening programmes, STD and AIDS programmes and reproductive health rights, (WHO 1994). The extent to which this has been adopted by the health services is not clear. The Health Department has a long history of d issem ination of fam ily p lanning in fo rm ation and m ore recently of disseminating STD/HIV/AIDS, information material. However, it appears to have been few if any, studies describing the development, distribution, dissemination, comprehen­ sion and utilization of reproductive health information material. The reproductive health task force (WHO 1994), however, revealed problems with health education provided by. health services. The task force found that nurses perceived that less value was attached to health information by their seniors, whom they felt were only interested in the number of 42 Curationis March 1999 contracep tives issued, rather than combining performance indicators and health promotion indicators. According to the report, some nurses had even stopped provid ing health education (WHO 1994). In another study among nurses in the Northern Province, K lugm an(1993) identified a lack of knowledge around reproductive health by carers. Specific areas that were deficient were emergency contraception, trea tm ent of rape victim s and STD treatment (WHO 1994, Reproductive Health Task Force). These studies may be show ing a g lim pse of a b igger problem surrounding reproductive health information that is available to nurses and the community as consumers. They suggest that a lthough the National Departm ent of Health and o ther organisations develop, distribute and d issem inate rep roductive health information, some does not reach the providers of health education or the health education system is not coordinated. It may also show that the information is underdeveloped or lacking. Mathews et al.(1998) conducted the study for a popular soap opera “Soul City” around health education. However, this study was done to assess the potential e ffectiveness of using audio visual presentations in the waiting rooms of South African primary health care clinics to educate patients about STD prevention and treatment. Published literature revealed no studies that exam ine the process of the distribution, dissemination and availability of reproductive health information in rural clinics have been done in South Africa. It is not known what reproductive health information is available at these clinics, w hich o rgan isa tions provide the information, how it came there or how clinic health workers(nurses) understand, interpret or utilise it for health education programmes in the communities they serve. Also little is known about how relevant reproductive health information is fo r com m un ities who are the consumers of the information. Health w orkers are the gatekeepers of rep roductive health in form ation , therefore, their contribution would give an in-depth understanding around the development, distribution,dissemination and consumption of reproductive health information. Literature show that there is compre­ hensive problems surrounding informa­ tion in general. These problems are even worse if such information is developed out of popular culture of consumers and users. Also some forms of communica­ ting information though popular are not easily understood by consumers (Sless 1981; Schlesinger 1978 & Golding &Philip 1976). The same literature suggests that these problems are minimised by use of surrogate consumers. The study done by Mellanby (et al.; 1996) on sex education found that there was a problem in sex education content provided for students from rural, semi urban and urban schools of England. However, it seems that there is little attention that has been given to the distribution, dissemination, nature and content of health promotion information in general. Studies tend to be on an individual outcome rather than on larger organisational issues, such as network analysis and the content of the message (Benton and McDonald 1992, Mealier et


INTRODUCTION
D uring the 1970s S outh A frica established an acute Family Planning Programme within the Departm ent of N a tio n a l H ealth and P o p u la tio n Developm ent(PDP).This program m e became a strong vertical family planning se rvice , w h ich e m b a rke d on m ass provision of contraception, while also run nin g e du ca tio n , info rm a tio n and communication programmes, (Klugman 1993).Since this period, the National Department of Health together with some organisations have developed, distri buted and disseminated family planning information materials to communities and clinics.South African health services faced a critical review during the pre-and post e le ctio n p e rio d s a ro u n d 1994.The co n ce p t of sexual and rep ro du ctive health was introduced in South Africa for the first time (WHO 1994).The inclusion of both sexual and reproductive health meant redefinition of demarcation lines.This definition suggested that traditional areas, such as maternal health and family p la n n in g , s h o u ld be b ro a d e n e d to include safe abortion services, cervical screening programmes, STD and AIDS program m es and reproductive health rights, (WHO 1994).The extent to which this has been adopted by the health services is not clear.The Health Department has a long history o f d isse m in a tio n of fa m ily p lanning in fo rm a tio n and m ore re c e n tly of disseminating STD/HIV/AIDS, information material.However, it appears to have been few if any, studies describing the development, distribution, dissemination, comprehen sion and utilization of reproductive health information material.The reproductive health task force (WHO 1994), however, revealed problems with health education provided by.health services.The task force found that nurses perceived that less va lu e w as a tta c h e d to h ealth information by their seniors, whom they felt were only interested in the number of c o n tra c e p tiv e s issue d, ra th e r than combining performance indicators and health promotion indicators.According to the report, some nurses had even stopped p ro vid ing health education (WHO 1994).In another study among nurses in the N orth ern P rovince, K lu g m a n (1 993) id e n tifie d a lack of knowledge around reproductive health by carers.S pecific areas that were deficient were emergency contraception, tre a tm e n t of rape victim s and STD treatm ent (WHO 1994, R eproductive Health Task Force).These studies may be s h o w in g a g lim p s e of a b ig g e r problem surrounding reproductive health information that is available to nurses and the com m unity as consum ers.They s u g g e st th a t a lth o u g h the N ational D e p a rtm e n t of H ealth and o th e r organisations develop, distribute and d is s e m in a te re p ro d u c tiv e health information, some does not reach the providers of health education or the h ealth e d u c a tio n syste m is not coordinated.It may also show that the information is underdeveloped or lacking.Mathews et al.(1998) conducted the study for a popular soap opera "Soul C ity" around health education.However, this study was done to assess the potential e ffe ctive n e ss of using a u d io visual presentations in the waiting rooms of South African primary health care clinics to educate patients about STD prevention and treatment.
Published literature revealed no studies th a t exam ine the p ro ce ss o f the distribution, dissemination and availability of reproductive health information in rural clinics have been done in South Africa.It is not known what reproductive health information is available at these clinics, w h ich o rg a n is a tio n s p ro vid e the information, how it came there or how clinic health workers(nurses) understand, interpret or utilise it for health education program m es in the comm unities they serve.Also little is known about how relevant reproductive health information is fo r c o m m u n itie s w ho are the consumers of the information.Health w o rk e rs are the g a te ke e p e rs of re p ro d u c tiv e health in fo rm a tio n , therefore, their contribution would give an in-depth understanding around the development, distribution,dissemination and consumption of reproductive health information.Literature show that there is com pre hensive problems surrounding informa tion in general.These problems are even worse if such information is developed out of popular culture of consumers and users.Also some forms of communica ting information though popular are not easily understood by consumers (Sless 1981;Schlesinger 1978& Golding &Philip 1976).The same literature suggests that these problems are minimised by use of surrogate consumers.The study done by Mellanby (et al.;1996) on sex education found that there was a p ro b le m in sex e d u c a tio n c o n te n t provided for students from rural, semi urban and urban schools of England.However, it seems that there is little attention that has been given to the distribution, dissemination, nature and content of health promotion information in general.Studies tend to be on an individual outcome rather than on larger organisational issues, such as network analysis and the content of the message (Benton andMcDonald 1992, Mealier et al 1996).

AIM OF THE STUDY
The aim of the study was to investigate availability and utility of reproductive health inform ation m aterials in rural clinics.The information gathered will help to improve the processes of develop ment, distribution, dissem ination and m anagem ent of rep ro du ctive health information material.
To describe the availability of reproductive health information that is present in rural clinics of the Umtata district.

2.
To examine the content of reproductive health information available at rural clinics of the Umtata district.

3.
To identify target groups for reproductive health information in the rural clinics.

4.
To investigate the extent and complexity of the language used in messages of reproductive health information.5.
To investigate how clinic health workers utilise reproductive health information materials.

RESEARCH METHODS
The Eastern Cape was chosen as a study area because it is mainly rural and has n ot been re se a rch e d extensively.Furthermore, the Eastern Cape has a lot of scope for service improvement.The Umtata district was chosen as it falls in the most rural and under served part of the Eastern Cape.The population of three hundred thousand live mostly (98%) in the rural areas (Transkei Census 1991).
The study was done in ten conveniently selected clinics in the Umtata district.

Study population
The study was done in ten conveniently selected clinics in the Umtata district.
Eight nurses were interviewed one in each of the eight clinics visited.In the two health centres visited focus groups of ten health workers each were conducted.Ten p rim a ry ca re health fa c ilitie s w ere selected to expose the variations between clinics.

Methodology
Qualitative methods were used to gather data related to the distribution, availability and use of re p ro d u c tiv e health information.Focus groups and sem i structured interviews were engaged in the clinics to get more information on how health workers in rural clinics interpret, understand, dissem inate and utilise re p ro d u c tiv e health in fo rm a tio n .Photographs and observational methods w ere used fo r c o lle c tin g data from posters hanging against the walls of the c lin ic s .The s tu d y co vered all reproductive health information available in the rural clinics, such as HIV, AIDS, sexually transm itted diseases (STDs), sexuality, reproductive cancers, and fam ily planning inform ation, such as posters and leaflets.

Data collection
An appraisal of available reproductive health m ate ria l in each c lin ic was conducted.A checklist was completed for each reproductive health material that was found and photographs of available posters were taken in each rural clinic.For every clinic the information related to the type of material, the producer, source, target groups, the approxim ate age, language, condition and circumstances of the display of posters and storage of leaflets were entered onto checklists.Though this study is mainly based on qualitative methods, the data collected by use of a checklist provided minimal quantification.
As clinics differ in terms of size, service and staff, the researcher chose the appropriate method to interview staff.Where nurses were two, semi-structured to in-depth interviews were conducted and one nurse was interviewed.In health centres where there were more than ten nurses two focus groups were conduc ted, however, nurses had to alternate so that clients were not left unattended.The focus group sessions were preferably conducted during the lunch hour, and lasted about 45 minutes.Interviews and focus groups were conducted in Xhosa, the mother tongue of the researcher and the subjects.
The nurses in the smaller clinics, though only two, managed to spend more time on in-depth interviews because of the steady flow of patients compared with the health w o rk e rs in h ealth ce ntres.Therefore, in-de p th interview s were conducted in smaller clinics.A tape recorder was used for both focus groups and the in-depth interviews with Curationis March 1999 43 the permission of the participants.Notetaking was d ifficu lt as there was no regular assistance.Limited assistance was offered by one member from the inform ation unit, as she saw it as an opportunity to learn and also visit clinics to collect monthly and quarterly statistics which is routinely sent to her office.

Descriptive analysis
All checklists were first counted for the total num ber of posters and reading materials available at all the clinics visited.This analysis indicated the distribution of p o s te rs and p a m p h le ts to c lin ic s .Secondly, the forms were counted accor ding to each clinic to assess variation betw een clin ics.Further d escrip tive analysis was done by looking at the type of material available at clinics, indicating the d is trib u tio n v a ria tio n by typ e. Analyses were done by theme and by clinic to examine distribution, inconsis tency and flow of information.Language use of the materials was analysed by vernacular or foreign to assess language use and suitability of reproductive health inform ation m aterials.Materials were examined by source to check distribution and development of those found.Posters were counted and grouped according to the developer or source and language used.The dates of issue or publishing were controlled for up-to-datedness of information available.The materials were analysed by target group to measure ta rg e tin g .The q u a lity and sto ra g e condition of materials were examined.Finally the materials were analysed by area of display and dissem ination of information by type.

Content analysis
The tape-recorded data of interviews and group discussions were analysed by identifying themes and topics.Sources of posters, information needs, language suitability, poster communication, health education, information dissemination, and information construction were the th em es id e n tifie d .Data w ere firs t organised into broad themes and then confined to specific topics.Validity and trustworthiness of data were maintained by keeping tapes recorded during focus groups, in-depth interviews and photographs of posters taken from clinics which would be made available to any researcher who m ight wish to analyse the data.

ETHICAL CONSIDERATIONS
The re se a rch e r a p p ro a c h e d the p ro v in c ia l hea lth a u th o ritie s fo r p erm ission to u nd erta ke th e study.Nurses in the selected rural clinics were informed of the study as the researcher approached relevant health offices during the planning phase of the study.At the clinic nurses received a consent form, which assured voluntary participation in the study.After reading the consent form th e s tu d y was e x p la in e d to them .C onfidentiality of all inform ation was ensured.Some reproductive health information materials from the National Department of Health and the district health office in Umtata were given to nurses in most clinics visited at the end of the interview or focus groups.Most health workers were interested and willing to participate in the study.The study was approved by ethics committee at the University of Witwatersrand.

Reproductive health information material
Distribution of posters did not show a correlation with the proximity to the urban area of Umtata, which was identified as the main source of supply of health information materials for all the clinics visited.The distances travelled to the clinics ranged from 10 to 70 kilometres from the urban area of the Umtata district.Three of the ten clinics are between 60 and 70 kilometres from the urban areas, while four clinics are within a radius of 20 to 45 kilometres, and the remaining 10 to 15 kilometres.The total number of reproductive health posters found in the clinics was twentythree (23).On the average there were two posters in each clinic.Pamphlets and leaflets on reproductive health were not available in most clinics.Only one clinic had pam phlets on STDs that were in English and stored in a cupboard and, therefore, not in circulation due to the language problem.

Display of posters
The posters displayed against the walls were in good condition, and only two were found tatty.Posters were mostly displayed in the waiting rooms, and in many of the clinics in a way that they were not catching the eyes of patients and clients.The inappropriate display was m ainly due to the design of c lin ic s ' waiting rooms.
In some clinics space was a problem and it a p p e a re d im p o s s ib le to d is p la y reproductive health information posters at suitable visible positions.There were a lso m a te ria ls on TB, E xtended Program me on Im m unisation, breast feeding etc., that took up space.The then Department of Health Transkei.

5
AIDS unit Department of Health in Bisho.6 Society for Family Health (SFH).
It was d iffic u lt to assess w hich c o m m u n itie s w ere ta rg e te d by the posters, since they tended to be rather universal and m essages w ere n o n specific.With the assistance of health w orkers it was concluded that most posters were targeting everybody.Two posters targeted teenagers.The varia tion of poster types and themes between clinics appeared to be greater than within clinics.

Sources o f inform ation for rural clinics
The information that reached the clinics was m ainly su pp lie d by the Umtata General H ospital com m unity centre.Health workers received m ost of the posters when attending meetings or at in-service training at the Umtata Hospital.S o m etim es the health in fo rm a tio n materials were provided on request but usually when the m aterials becam e available.Posters were not delivered to clinics.There was no system for health workers to order any health information material.They did not know how or where to order information material.
They accepted what was given to them by the hospital and never asked what was available or not, since they never knew what was supposed to be available.There was no catalogue at the clinics to assist them in ordering the information they wanted.On Only one instance a health w orker had ordered diabetes information from a centre in Durban and Braamfontein.Aids co-ordinators were another soruce of reproductive health information.
H ealth w o rke rs d id n ot have the opportunity to order reproductive health information, which in their opinion was needed for their communities.Health workers believed that the communities somehow differ, and that reproductive health information could be needed by one co m m un ity, but not by others.
Communities, to a limited extent, differ in term s of the prevalence of diseases, social class and literacy.Therefore, a c q u irin g any ty p e o f in fo rm a tio n because it is supplied did not help their communities much.Health workers would like to be provided with catalogues and centres where to obtain reproductive health information for ordering purposes.They never received enough m aterials from suppliers like Umtata H ospital to provide fo r th eir communities and especially the schools in their area.
Six themes were observed in the posters.AIDS awareness was covered by ten posters, while family planning by eleven.
There was one poster on youth sexuality and two posters on condom use.No posters were available on STDs and reproductive cancers.No publishing date was noticed on any posters at the ten clinics.However, some of them must be several years old as th ey w ere produced by the former Departments of Health.

Language and Culture
Posters were mostly in English, a few in English and Xhosa, and others in English and Afrikaans.M ost of the English p o s te rs w ere fro m the N atio na l Department of Health, FSH, Lygnon ED and Berfumed.The English and Xhosa posters were p roduced by the then Transkei Department of Health.
In some cases the language used in p o s te rs was to o a ca d e m ic to be understood by com m unities.Health w orkers reported that som etim es the terminology was not easily translated to vernacular language.Though English posters were inappropriate, they could be bilingual in most cases, e.g.Xhosa and English.Health workers reported that English posters were not helpful for illiterate communities.Health workers felt that in some instances reproductive health language, which was used in the posters available, was very sensitive when translated into Xhosa.
Some posters and pamphlets did not c o n s id e r the c u ltu ra l a sp e cts of communities.In some instances these posters did not consider the norms and values of the co m m un ities.In m ost communities that are served by these, it is taboo to call reproductive organs by their real names.C om m unities could consider this as vulgar and unprofessional.Development and conceptual development of repro ductive posters should be culturally based and should reflect local reality, e.g.posters with kraals and thatched huts would be better understood by commu nities.Health w orkers fe lt that m ost reproductive health posters were too abstract, very urbanised and in some cases did not m ake sense to local communities.Most people did not ask questions about posters.
Health workers reported that posters on w om en's reproductive organs were a source humiliation to men, who closed th eir eyes when show ed the fem ale reproductive organs.Women also turned their eyes away from the posters on male reproductive organs.In other words such posters did not provide any form of education for communities, but were a source of embarrassment.
Health w orkers believe that explicit posters should be reserved for school pupils and not for the older generation in the communities that the health workers are se rvin g .R e p ro d u c tiv e health inform a tion d eve lo pm e nt should be sensitive to the communities' attitudes.The construction of reproductive health inform ation material should consider local lan gu ag e th a t is a ccep ted by communities."There is always a local acceptable language, which is usually known by many people in an area, that is why posters should be developed locally" one nurse said.
P osters th a t w ere a v a ila b le on reproductive health were meaningful to health workers and they understood the messages.Most posters, however, did not co m m u n ic a te m uch.In som e instances there was a great deal of irrelevance between the words and the picture on the poster that they might be conveying.
Health workers were of opinion that a p o s te r s h o u ld not need w o rd s to c o m m u n ic a te a m essage.P ictures sh o u ld be se lf re lia n t in p assing messages to communities.Posters on clinic walls should speak for themselves, especially for the illiterate who cannot read what the words are explaining on an unclear poster.For example, a poster on female reproductive organs bears no meaning to an illiterate woman, because she does not know what the uterus looks like, unless they are first taught that " this is how the cervix looks like" one health worker explained.

DISCUSSION
The re su lts sh ow th a t th e re is no correlation between the proximity of the s u p p lie r and the a v a ila b ility of reproductive health information to rural clinics.It also appears that posters are w id e ly d is trib u te d as c o m p a re d to pamphlets and leaflets on reproductive health information materials.The results show that posters are widely distributed and are in line with the study done that states photographic information though p ro b le m a tic p la ys a m ajor role in education (Sless 1981).These results a lso reveal th a t re q u is itio n in g of reproductive health information is grossly unbalanced.More family planning and AIDS aw a re n ess in fo rm a tio n are distributed than STDs and reproductive cancers.This has an impact on the flow of information to target communities.Another important discovery of the study is a greater variation of inform ation between clinics than within clinics.
V a ria tio n s of th e m e s co ve re d by reproductive health information materials between and within clinics show some degree of inconsistency in the flow of information to communities.While it is possible that different clinics have needs in re p ro d u c tiv e hea lth in fo rm a tio n m aterial, there was no evid en ce to suggest that this was the consequence deliberate strategy.Again this is a point on the distribution and flow of information to target communities.The results reveal that unorganised distribution of health information materials on reproductive health will result in redundancy and confusion in the flow of information as m essages from d iffe re n t p ro d u ce rs tended to contradict.
The study shows that development of health in fo rm a tio n m a te ria ls on reproductive health has no publishing dates.This alone shows that construction of reproductive health materials is not updated and therefore, again faced with redundancy and is out of context in terms of the information needs of communities.The use of mainly English in the materials distributed on reproductive health shows the ignorance of the developers to their audience.If they are not ignorant, they are not sensitive to the audience.The study indicates that the concept of an inferred audience is valuable if posters and their messages are aiming at effective communication.The inferred audience is sometimes a necessary guide in the construction of messages, particularly in the use of language (G elding 1976;Schlesinger 1978).
Health workers reported that their clients seemed not to be interested in posters that were displayed.For health workers this lack of interest is attributed to the s o p h is tic a tio n of p ictu re s and p oo r c o m m u n ic a tio n on th e p a rt o f th e reproductive posters.Health workers' views of posters for being to o a bstract and u rbanised m ay be coming from the general view that visual communication is a major transmitter of c u ltu ra l h e rita g e .P eople te n d to und ersta nd w hat is fa m ilia r to th e ir environment.From a socialisation stance the message on the poster becomes far more removed from the audience that it becom es problem atic, because each generation must regenerate concepts, which they understand well (Sless 1981).
Therefore, posters are generated by another generation for other generations.Generation in this particular case refers to different comm unities, which share different values, norms and conceptual background.Communities that develop posters are different from the consumer who are communities in this particular case.Pictures have definition because they have been endowed by individuals in a s o c ie ty or g e n e ra tio n , w ho understand the concepts it developed.P osters do n ot have d e fin itio n to consumers because they have to deal w ith c o n c e p ts th a t th e y have n ot generated.
The supply of the information to rural clinics without considering the need of the particular community is another fact that cannot be disregarded in this study, as it could be linked to the insensitivity of p ro d u c e rs and s u p p lie rs to the information needs of these communities.This insensitivity, detected by the study, re ve a ls a lo g ic a l im p e ra tiv e to construction of posters that does not serve much purpose if it is not consumed as expected.
The stu d y illu m in a te s th a t p ic to ria l education, which takes place outside a popular culture is not good enough.Most people as reported by health workers do not bother about asking questions about posters.This may suggest that though people see pictures they do not think deeply about them.Another discovery is that posters are not simple and self evident as one would imagine.Most posters are supported by a lot of words to say something.It appears that without words communities and other users of posters would need graphic designers and developers to stand next to them and explain.Besides, lots of words on posters pose redundancy.
Health workers seem to be dissatisfied with the way they were supplied with the information.It appears that there was a problem in ordering sufficient quantities of reproductive health information by the source.The problem was twofold as the then Transkei Department of Health was no longer developing posters, and they d e p e n d e d on m a te ria ls fro m AIDS coordinators.The source also does not have a systematic way of ordering the information that would enable adequate information supply for clinics.There is, however, a system of distribution which is based on m eetings and in service training.
Though there is this type of information distribution, health workers want to order in fo rm a tio n th em selve s and n ot be supplied by the available source.This is a reasonable dem and, since h e a lth w o rk e rs fe el th a t th e y are sometimes supplied, to their opnion, with what is not suitable for their communities.The study also shows there is a need for re p ro d u c tiv e health in fo rm a tio n catalogues for health workers to order in fo rm a tio n on the basis of w ha t is available.
Though health workers emphasized lack of understanding of posters between their clients and patients, it is not clear whether clients lack the necessary cognitive skills to affect the required transformation of posters.Health workers mentioned that clients would not be able to recognise a cervix on a poster unless they have been taught.
However, the study does not clarify whether clients make errors at the level of transposition when recognising th e p ic tu re s of re p ro d u c tiv e health posters.It is hoped that further study will be able to give some clarity in this area.
The study suggests that a system of poster developm ent needs to change and certain rules should be formalised in the process.Some questions should be asked, like w hat kind of inform ation should be shown, what education point n ee ds to be m ade, w h a t w ill the consumers or target groups do with the information, and can previous posters be reproduced.

CONCLUSION
In c o n c lu s io n re p ro d u c tiv e h ealth information for rural communities in the Eastern Cape is inconsistently d is tri buted, poorly disseminated, insufficient, too abstract, redundant, not updated, communicated in a foreign language, not self reliant to education, and lacks clarity.It is dominated by family planning and AIDS awareness and does not provide other reproductive health aspects such as reproductive cancers and STDs.More posters than pamphlets are distributed.Inform ation does not have publishing dates.In summary, posters are available, but judging from the responses by health w orkers they are p ro b a b ly fa ilin g to communicate health messages.

RECOMMENDATIONS FOR REPRODUCTIVE HEALTH INFORMATION
Several recommendations are made for im proving this type of service.These include the local development of repro ductive health information which should be culturally based reflecting local reality.S o u rce s and a vailab le re p ro d u c tiv e health information material should be in catalogue form and available to nurses.An organised distribution of reproductive health information should be organised fo r ru ra l c lin ic s .The la n g u a g e o f reproductive health information material should be acceptable to consum ers.Reproductive health information should be disseminated in large quantities for wider distribution to consumers.Umtata a rea n ee ds a c le a ra n c e hou se.Reproductive health information materials should be in pamphlet and poster format.Reproductive health information material should cover a wide range of reproduc tive health problem s.Reproductive health information material should have a p ub lish in g date.For m ajor health issues such as AIDS new inform ation should be provided all the time.
Furthermore, materials from Water Affairs, T ra n sp o rt, W elfare and A g ric u ltu re Departments seemed to com pete for space at the clinics visited.Because of th ese p ro b le m s m e n tio n e d , health workers suggested that flip charts could display posters on a weekly basis or whenever necessary.The space problem at th e c lin ic s m eant p o s te rs w ere removed from the walls whenever new ones arrived.The health workers found changing of posters time consuming and rather hazardous as they used ladders for this.R eproductive health inform ation was barely sufficient to display at clinics, and therefore, not serving its purpose of c o m m u n ity e d u c a tio n .O nly th ose people, who attended clinics had an o pp o rtu n ity to know anything about health inform ation m aterials.Health workers believed that reproductive health information materials should be available to e verybody and not only to c lin ic a tte n d e e s.P osters s h o u ld a lso be available at public centres like schools, churches, shops and against telephone and electricity posts like many adverts.The producers of posters were identified by th e ir o rg a n is a tio n 's name at the bottom of the poster.Producers that were identified were the various past and present governm ent D epartm ents of health and NGOs.They included: