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Item Open Access TB control: a matter of lifestyle(University of the Free State, 2005) Verbergt, Greet; Foblets, Marie-Claire; Meulemans, HermanEnglish: In the West, TB was controlled before there was medication on the market. In South Africa this is far from the case: the inheritance of apartheid, poverty among certain social groups, and an exponential increase in HIV/AIDS make TB control almost impossible. The co-existence of two medical traditions (the Western medical system and traditional healing) exacerbates the challenge of finding effective measures for TB control. This paper aims to understand the underlying patterns of the persistant spread of this disease. Its point of reference is Max Weber’s notion of Stilisierung des Lebens, or lifestyle, in which the dialectic process of “chance” and “choice” plays an important role. In the category of chance, much can be done by policy-makers to create successful healthcare programmes, such as DOTS within TB control. Policy-makers, however, are not the only players responsible. Individuals must also take responsibility by opting for the chances provided. Even then, the spectre of the past may continue to bedevil the health outcomes of South Africans as they endeavour to build a new nation.Item Open Access Staff capacity and resources at nine Free State clinics: shortcomings in the TB programme(University of the Free State, 2005) Janse van Rensburg-Bonthuyzen, EgaEnglish: South Africa faces a continuously escalating tuberculosis (TB) epidemic. This article explores the extent and nature of shortcomings in intra-clinic TB programme resources and staffing. Data was gathered by means of in-depth interviews and observations in nine clinics in the Free State. The main findings of the study include the following: not all TB programme co-ordinators or implementers in the nine clinics had been formally trained in the principles of the National TB Control Programme; knowledge of TB diagnosis was limited; the treatment volunteer system was not optimally managed or utilised; policy guidelines were not available at all facilities; the recording and reporting infrastructure at some clinics was flawed; the drug, supply and equipment infrastructure at some clinics was lacking; the information, education and communication infrastructure was not utilised to its full extent, and management support was in need of improvement. The findings of this study should alert TB programme managers at the provincial, district, local and clinic levels to the existence and extent of problems at some primary health care (PHC) clinics and the urgent need to address them.Item Open Access Hospitalisation for TB in the Free State: opinions of health workers and managers(University of the Free State, 2005) Heunis, ChristoEnglish: Non-governmental health care providers in the Free State have traditionally provided long-term hospitalisation services for TB patients. This history now appears to have come to a halt. This paper documents the opinions of a purposive selection of public health workers and managers with regard to TB-related hospitalisation. The views and experiences of health workers and managers at the district, provincial and national levels were recorded by means of self-administered questionnaires and personal interviews over the period 2001-2003. In the Free State this period was characterised by a range of intricate problems. Indications are, however, that public district hospitals are capable of dealing with the burden caused by the sequential closure of the former Allanridge Chest and Santoord hospitals.Item Open Access Elements and principles of a strategic communication approach to health promotion in a multicultural context(University of the Free State, 2005) Pauwels, LucEnglish: Health communication projects are a key instrument in disease prevention and alleviation, as well as in health promotion and education in a broader sense, but only to the extent that such efforts are grounded in a thorough understanding of the general context of the health issue concerned and if developed in concert with other instruments and aspects of health care. Such a complex undertaking calls for a strategic and integrated approach involving many different types of expertise and research. This article briefly introduces a broad model for strategic health communication planning that is firmly grounded in the issue of health care at large. The focus then narrows to a discussion of certain aspects of health communication planning in a multicultural environment. To this end, some concrete suggestions are provided to assist policymakers, fieldworkers and researchers in evaluating or setting up effective communications in a health context.Item Open Access Economic evaluations of diagnosis and treatment programmes for tuberculosis in developing countries: a review(University of the Free State, 2005) De Graeve, Diana; De Ridder, Annemieke; Smet, Mike; Van De Poel, EllenEnglish: This paper reviews recent economic evaluations of diagnostic pathways and treatments of TB in poorly resourced and highly burdened countries. The limited number of studies and their methodological weaknesses make it difficult to draw strong policy conclusions, especially in the field of diagnosis. The evidence points to a possible gain in cost-efficiency by moving from the Ziehl-Neelsen staining method to fluorescence microscopy and from three to two sputum examinations. Nevertheless, further research is indispensable. Concerning treatment, the community-based DOTS approach has proved more cost-effective than the conventional approach. With respect to other treatment alternatives, less evidence is available, but two promising possibilities are the expansion of DOTS by collaboration with the private sector and the introduction of second-line drugs for chronic disease.Item Open Access One patient, two diseases: collaboration in controlling TB and HIV in the Free State(University of the Free State, 2005) Peters, Annatjie; Heunis, ChristoEnglish: A perilous synergism exists between TB and HIV/AIDS, which form a dual epidemic requiring joint action. This paper first reviews key global and South African policy developments in relation to TB-HIV/AIDS control. Secondly, the early response of the Free State to global and national directives to implement integrated TB-HIV/ AIDS programmes is described. As is clear from the experience of the first TB-HIV training site in the Free State, the Mafube local municipality, integrated TB and HIV/AIDS control is made possible by means of actual practical interventions as well as the collaboration of a range of role-players. In Mafube, and later also in the Free State at large, attempts at integration have resulted in substantially more TB patients undergoing voluntary counselling and testing for HIV.Item Open Access Posters, billboards and grassroots media relating to TB and AIDS in the Free State and Lesotho(University of the Free State, 2005) Pauwels, LucEnglish: This contribution examines the TB- and HIV/AIDS-related health promotion materials currently in use in the Free State (South Africa) and in Lesotho. It first considers the cultural implications of choosing various visual and verbal design elements in a health-related message. It then analyses a number of health promotion posters on the basis of research findings and the general principles of message design in a multicultural context. Finally, a visual essay approach is taken, commenting on the roadside billboards and alternative health promotion media encountered in the Free State and Lesotho.Item Open Access Healthcare-seeking behaviour among clinic-based tuberculosis patients(University of the Free State, 2005) Matebesi, Zacheus; Meulemans, Herman; Timmerman, ChristianeEnglish: This study investigated the factors influencing recourse to healthcare in a sample of 220 tuberculosis (TB) patients. Data collection was by means of face-to-face interviews. Patients sought help mainly from primary healthcare clinics (46%) and private doctors (40%). The mean patient delay was seven weeks, with only 21% of patients seeking professional healthcare within less than two weeks. The results show that lack of awareness of TB and use of a home remedy were significantly associated with a delay of longer than two weeks in seeking healthcare. These findings indicate an urgent need to educate communities on the signs and symptoms of TB, as well as the need to attend designated health facilities for early diagnosis and proper treatment.Item Open Access Social capital and community TB care in the Free State, South Africa(University of the Free State, 2005) Meulemans, Herman; Van Ouytsel, Jeff; Rigouts, Leen; Mortelmans, Dimitri; Heunis, Christo; Matebesi, Zacheus; Van Rensburg, DingieEnglish: Where do TB patients turn for help in the South African health care system? Do they go to a clinic or a community health centre for ambulant treatment, thus retaining contact with their families and local communities? Or are they hospitalised, which means that they can no longer perform their normal duties? In order to answer these questions, a data set was compiled on the basis of oral interviews with a stratified random sample of 310 pulmonary TB patients in the Free State province. A logistic regression analysis of the data revealed that TB patients who can rely on an extended network of relationships, with relatively large amounts of social capital at their disposal, generally make use of clinic treatment and community TB care. Clinics play a central role in TB control programmes, not only as a locus of treatment, but also as a point from which patients can be referred to higher echelons in the healthcare system.Item Open Access High strain diversity among isoniazid-resistant M tuberculosis isolates from the Free State and Northern Cape provinces(University of the Free State, 2005) Mokhethi, Zac; Van der Spoel-Van Dijk, Anneke; Van der Zanden, Adri; Rigouts, LeenEnglish: This study set out to determine the diversity of the isoniazid-resistant M tuberculosis isolates causing pulmonary tuberculosis in the Free State and Northern Cape provinces of South Africa. Thirty-seven isoniazid-resistant isolates from a nation-wide survey could be fingerprinted by IS6110-based RFLP. Spoligotyping and MIRU-VNTR typing were performed to confirm inconclusive results. The number of IS6110 copies per isolate varied from 2 to 18, with nine (24.3%) isolates harbouring five insertions or fewer. Nine (24.3%) of 37 cases grouped into four RFLP-clusters. The clustered isolates with fewer than five IS6110 copies were all shown to be different when subjected to spoligotyping and MIRU-VNTR typing, whereas the clustering of the high-copy isolates was confirmed. The high degree of diversity among H-resistant isolates in the Free State suggests a low recent transmission rate, but this should be investigated by long-term analyses. For the Northern Cape province, representative sampling is needed before proper conclusions can be drawn.Item Open Access DNA fingerprinting analyses of M tuberculosis-complex isolates from the Free State, South Africa, as part of a multidisciplinary study(University of the Free State, 2005) Van der Spoel-van Dijk, Anneke; Mokhethi, Zac; Khumalo, Macala; Shamputa, Choala; Matebesi, Zacheus; Van Rensburg, Dingie; Portaels, Françoise; Rigouts, LeenEnglish: The objective of this study was to serve as a complement to socio-economic analyses of TB patients in a DOTS system, providing microbiological data and documenting the TB population dynamics. Sputum samples were collected from smear-positive TB patients in the Goldfields, Thaba Nchu and Qwaqwa areas. Laboratory analyses comprised the culturing of Mycobacterium tuberculosis isolates and DNA fingerprinting. The primary aim was hampered by problems encountered during specimen sampling, inadequate resources, and a low culture-positivity rate. Nevertheless, the fingerprinting data of a random sample showed a heterogenous TB population, suggesting that reactivation might be an important factor in the area studied. Clustering was the highest in the mining area. Preliminary data from serial isolates also detected possible re-infection during treatment or initial mixed infections in five of the eleven patients.Item Open Access Challenges to effective control of tuberculosis and drug resistance in African countries(University of the Free State, 2005) Rigouts, Leen; Portaels, FrancoisEnglish: Drug-resistant tuberculosis (TB) appeared soon after the introduction of chemotherapy and is considered a man-made phenomenon. Despite the efficacy of short course chemotherapy, which includes a cocktail of drugs and has been generally recommended since the 1960s, increasing numbers of multi-drug-resistant (MDR) cases were reported worldwide in the early 1990s. In the WHO’s 2004 report on surveillance of drug-resistant TB, MDRTB is reported from over 100 countries. Although little data is available on drug-resistant TB in Africa, this paper presents an overview of the current situation on the African continent, which is severely affected by the TB epidemic.Item Open Access Tuberculosis control in South Africa: reasons for persistent failure(University of the Free State, 2005) Van Rensburg, Dingie; Janse van Rensburg-Bonthuyzen, Ega; Heunis, Christo; Meulemans, HermanEnglish: This study reviews the origins and spread of tuberculosis in South Africa in the international context. It shows that TB is far from being under control, despite the availability of effective technology. Five arguments offer explanations for this failure. First, control strategies fail to eradicate the macro-conditions that create a breeding ground for TB. Secondly, new disease conditions — especially HIV/AIDS and MDRTB — confound efforts at control. Thirdly, the health system and its priorities are insufficiently focused and resourced to cope with TB. Fourthly, healthcare staff responsible for TB care are often weak links in the chain of control. Fifthly, TB patients fail due to ignorance, delay in seeking care, and non-adherence to treatment regimens. TB consequently remains a major public health challenge, today more than ever in its protracted history.