Combating tuberculosis - lessons learnt from a rural community project in the Klein Drakenstein area of the western Cape

Objective. To describe and evaluate a lay worker project designed to enhance the effective control of tuberculosis in a rural/farm setting. Design. A descriptive cohort study using both qualitative and quantitative research methodology. Setting and participants. Farming community in the Klein Drakenstein area of Paarl, Western Cape, with health services provided by the Cape Metropolitan Council. The adherence of patients receiving tuberculosis treatment from 1 January 1993 to 31 December 1995 was analysed. The acceptability of the project was assessed using in-depth interviews with key stakeholders. Results. A cohort of 402 tuberculosis patients was included in the study. This cohort was divided into the patients from farms that had participated in the project (intervention group) and those that had not (nonintervention group). The adherence data for children and adults were analysed separately. The adherence rates for children in both groups were the same (RR = 1.00, 95% CI 0.88 - 1.14), whereas the adherence rate for the adult intervention group was significantly better than that of the non-intervention group (RR = 1.19, 95% CI 1.08 - 1.31). The qualitative component of the investigation indicated a high level of commitment to the intervention from the members of the implementation team, the farm health workers and their employers. The farm health workers described how their role had assisted their communities and had improved their own perceptions of self-efficacy. The close bond that they had developed with the formal health sector had improved the access of the labourers on the farm to primary health care. Although the project had commenced as a tuberculosis initiative, the farm health workers were dealing with a variety of health issues. Their ongoing training was designed to facilitate this development. The formal health sector found their activities facilitated by the easy access that they had with a representative from each farm. The employers were satisfied that the project had increased the cost-effectiveness of their economic endeavours. Conclusion. This farm worker project appears to be a model of a well-designed and expertly managed community-based project for tuberculosis control in rural/farm areas.