COMMUNITY PERCEPTIONS OF BIOMEDICAL HEALTH CARE IN A RURAL AREA IN THE NORTHEW PROVINCE SOUTH AFRICA

Tlze success ofstrategies to revitalisepriiiimy health care sei-vices such as tliose advocuted by tile BaiizaA-o Initiative requires a respoiise adapted to tile expectatioiis oftlzepopulation, especiallj? b~ terizzs of qualify. Tlie goal of this study was to irivestigate co17imun~~percepfio1zs ofavailability, accessibility, acceptability and affoi,dabilir), ofbionledical healtlz cure service,^ iiz a rum1 area of tile Northerii Proviilce iii Soutli Africa. A iiiulti-stage cluster sanlpling nzetlzod was used to msure randoin iilclusion of respondeizts. Tlzesaiiiple coizsisted of 85 iiien (49%) and 89 ivomeiz (51961, the age rai~gedfionz 18 to 88yeai.s with a ineaii of32.8 (SD=13.9). Particil~ants were iizterviewedf&ce-to-Jbce witli a structui.ed questioiinaire on demographic and health faciliv data, healtli statu.~, accessibilil),, affoi,dabili@, al~ailability and quality of liealtl7 care, and a Healtli Beliefs Questionnaire. Resultr indicate a Iolv acceptability ofbioiiiedical healtlz care: 78%feIt that tile iiiedical sen,icer are pool: Tlzere was a significaiit relationship beiweeil not being nzenlber o f a rizedical sclzen~e, poorer health status and availabiiil)) of health ca1.e services. The poorer healtlz status ivas also sigizificaiitl~, related ivitlz acceptubilih, of healtlz seivices. Illizess afO'ibutes, eiizployllzent status, gender and lzealtlz beliefs were not related to aiiy ofthe health sewices/~ai.anieters. It is suggestedtiiatpi,iizzaiy 11ealtli carepolio; takes cogizisaiice of tlie existing d~feielrizces like that ofacceptability aild affoi.dabilit)t iiz atfitudes toiuai.d bioiiiedical heulflz care.


INTRODUCTION
Medical facilities in the Northeln Province are inadequate considering the size of tlie population.In 1992 there were 4.7 hospital beds available per 1000 people.The national average is 5.1 beds, and 6.5 beds per 1000 people in Gauteng.The Northern Province is in dire need of medical officials, having only 796 practitioners for 5.3 million people in 1992 or 0.2 per 1000 people.The national average is 0.6 doctors per 1000 people.Another important determinant of health status is the availability of health facilities.This includes accessibility and quality of service.In general, health facilities are more readily available in urban areas.However, these facilities have a strong curative bias, and inany are situated too far from wliere the poor people live.Rural people not only have limited facilities, but access to these facilities is also restrictcd.People living further than 5 knl from medical facilities constitute 44.4% oftbe population, whlle I 1.3% belong to a medical aid benefit fund in the Northern Province.Health status is not only determined by access to facilities for mainly curative purposes, but also by other factors which prevent the onset of illness and malnuhition.lncome is seemingly the most important factor in this regard, as there is a strong correlation between income levels and health status (Development BankofSouthern Africa, 1998:53).
The health care needs in rural South African environments are mainly addressed by traditional or faith healers and prilnary health care clinics run by nurses.In the light of the absence of medical doctors in HEALTH SA GESONDHEID Vol. 5 No. 1 -2000 near reach this study reflects on the attitudes towards availability, accessibility, acceptability and affordability of biomedical health care services in a rural area of the Northern Province in South Africa.Little attention has been paid to the quality of primary health care services in developing countries.This can be explained by the priority that has long been placedon improving availability of services in contexts where there have been enormous needs that have rarely been met.The evaluation of the quality perceived by the public is justified in the desire to meet users expectations, thereby contributing to the process of democratisation of health care services (Haddad, Foumier, Machouf& Yatara, 1998:382).
During the Reconstruction and Development era, in South Africa, very little literature is found on the provision of Primary Care Services (Thipanyana &  Mavundla, 1998:23).Van Vuuren and Botes (1994:2) found among a culturally diverse population in an urban area in South Africa (greater Bloemfontein) that variables such as population group, age and employment status influence their attitudes towards professional health care.They further emphasise the importance of bringing these issues to the attention of the health care policy makers.Miralles and Kimberlin (1998:345) found among elderly from different socio-economic backgrounds in Rio de Janeiro that residents of the low-income community reported less availability of services, more difficulties with affordability and greater acceptability of pharmacy services than their high-income community counterparts.Heap and Ramphele  (1991 : 11 7) studied health care strategies among residents of South African hostels indicating that choice of therapy depends on cost, availability, and experience with various healing systems.Haddad, Fournier, Machouf et al. (1998:381) studied community perceptions of primary health care services in Guinea.From a taxonomy of perceived quality the following categories were identified: (1) technical competence of the health care personnel, (2) interpersonal relations between patients and care providers, (3) availability and adequacy of resources and services, (4) accessibility and (5) effectiveness of care.On Tanzanian women's views of the quality of Primary Health Care Services, Atkinson and Ngenda (1996:3ff.)found 6 dimensions: (1) conduct of health staff, (2) technical care, (3) convenience ofthe health facility, (4) organisation of the health care, (5) h g s and (6) structural aspects.In addition, the role ofworldviews in health case systems has been acknowledged (Craffert, 1997:l;Hildebrandt, 1997:155;Pillay, 1996:4).
Considering the above components and concepts of care and quality ofhealth care, the purpose ofthis study is to examine the concepts of availability, accessibility, acceptability, and affordability as applied to biomedical health care in a rural South African community (Anyinam, 1987:803).
It is hypothesized that illness attributes (medical, supernatural and psychosocial), socio-economic status, subjective health status, member of medical scheme, and distance to health facilities have an impact on the attitude towards biomedical health care in terms of availability, accessibility, affordability and acceptability.On the basis of these parameters questionnaires were chosen, which were previously used on South Africanpopulations, to measure "quality ofhealth care" and "healthbeliefs".
A multistage cluster sampling inethod was used to ensure random inclusion of respondents fron~ the GaMolepo area, which is 60 knls southeast of Pietersburg (cf.Van Vuuren & Botes, 1994:3).In the first phase villages from the GaMolepo area were randomly selected; in the second phase dwelling units representing households were randomly selected, and the third phase involved the identification of a single respondentper residential unit.
Participants were interviewed face-to-face with a structured questionnaire by a trained African interviewer (with a matric qualification and fluency in English and Northern Sotho) in the language of the participants.

Inventory
The structured questionnaire consisted of 13 items on demographic and health facility data, 1 item on health status, and 17 items on Quality of Health Care (cf.Van  Vuuren & Botes, 1994:3f.), and a 30-item Health Belief Questionnaire (HBQ) (Pillay, 1996:5).The questionnaire was tested with 10 participants, which did not form part of the final sample in order to ensure validity andreliability.
The quality of health care questionnaire consisted of HEALTH SA GESONDHEID Vol. 5 NO. 1 -2000 fou-comnponents: accessibility (3 items), affordability (5 items), availability (3 items), and acceptability (6 items).Answers were rated on a five-point Likert scale from l=agree fully to 5=disagree strongly.The Cronbach alpha as well as the split-half reliability coefficient for the quality of health care questionnaire was .7 for this sample.
The HBQ consisted of 20 items etiological beliefs (10 external ancestraVevi1, 4 medical, 4 self-blame, and 2 physical weakness or body malfunction), 8 items treatment beliefs (4 self-medication, home treatment, 2 medical, 1 prayer, 1 holistic treatment), 2 item preventive belief (1 self-care, 1 hygiene).The items can also be divided into 8 items for medical attribution, 12 items for supernatural attribution, and 10 for psychosocial attributions.The HBQ is designed to ascertain health and illness beliefs.It requires the respondents to rate on a fow-point Likert scale whether they agree, sometimes agree, disagree, or were not sure about the statement presented.The Cronbach alpha and split-half reliability coefficient for the HBQ was .81 and 3 5 , respectively, for this sample.

RESULTS
Most (137) (79%) were not members of a medical aid scheme, whereas 37 (21%) were.From those who were employed the mean monthly income was R 1 844 (SD=1354), range R 300 to R 5 600.The nearest clinic was estimated at a meanof4.8km (SD=5.2),range 1 to 29 km, and the nearest clinic in minutes: mean 38 minutes (SD=22.3),range 4 to 120 minutes.Thenearest doctor was estimated at a mean of 20.3 km (SD=X), and the nearest doctor in minutes: mean 55 minutes (SD=29).The nearest hospital was estimated at a mean of 24.8 km (SD=13.3),and the nearest hospital in minutes: mean 75 (SD=46).
Most participants (33%) rated their health with excellent, whereas 20% rated it as good, 24% reasonable, and 21 % as poor.
Table 1 indicates the availability, accessibility, affordability and acceptability of health care in percent.Regarding availability 84% of the participants felt that there are not enough fanlily doctors intheir area.On the other hand almost one-third (31%) tended to use medical services just because it is available.More than one-third of the participants stated problems with the 17"Over-the-counter drugs are often better than medicines docton prescribe i 26 1 15 i 59 i I AF (=Agree fully).A (=Agree), U (=Unsure), D (=Dmagree).DS (=Disagree strongly) accessibility of biomedical health care, like 43% felt that clinics should remain open after business hours and 38% that one can never see the doctor without an appoinhnent.About two-third (63%) ofthe participants felt that one should receive free medical care in the hospital and 56% would rather go to a clinic where medical treatment is free.On the one hand almost half (49%) agreed that medical services are expensive and have even heco~lle more expensive (43%) but on the other hand 38% agreed that doctors are not expensive considering the type of service they give.The acceptability of health care in the GaMolepo area was generally considered poor: 78% felt that the medical services are poor, 71% felt clinic nurses should refer their patients for test more often and 51% agreed that nurses are so busy that they can not look after their patients properly.There was high trust in biomedical healthcare since 59% noted that over-the-counter drugs and 50% that home remedies are not better than medicines doctors prescribe.
Table 2 shows the correlation between independent variables and attitudes towards health care.
There was a significant relationship between not being amemher of amedical scheme, poorer health status and availability of health care services.The poorer health status was also significantly related with acceptability of health se~vices.Employment status and gender was not related to any ofthe health servicesparanleters.
There seems to he a significant association between increasing age, member of a medical scheme, poorer health status and the statement that there are insufficient family doctors (GPs) in the area.The other two health indicators (free hospital care and improved referral by clinic nurses for tests) Were not related to health status and medical scheme membership.(4) illness is caused by infection; and (5) people inherit illness from their parents.Interesting is that participants agreed to a large extent that older people play an important role in tenns of knowledge about illness, advise and treatment.The most important supernatural attribute was doctors can make the illness better hut they cannot treat the cause.In addition, people should pray and observe rituals to prevent and treat illness.Across the three categories of health attributes medical was most important, followed by psychosocial and supernatural in that order.
The three health belief attributes (medical, supernatural, and psychosocial) were correlated (using  This study found a mean distauce of 4.8 km from the consumer's home to the nearest primary health care centre.The norn~al distance between home and clinic is considered to be between 2-5 km.Vlok (1991: 5ff.) states that The Prirna~y Health Care clinic must be accessible to the com~nuuitv, i.e. it should be within 5 that among the urban Black cornlnunity in Bloemfontein (66%) (Van Vuuren andBotes, 1994:3) but the reverse was true for using medical services as they are just available.Regarding accessibility thc participants in this study found their health services more accessible than that of the urban Black comnlunity (e.g.43% felt clinics should be open after business hours as well as opposed to 83%).Regarding the other health parameters thepa~ticipants in this study generally gave similar responses to that of the UI-ban Black community.An exception was that 64% of the latter agreed their quality of health services is excellent whereas only 13% of the participants in this study did.This may be explained by the greater accessibility of biomedical health care in the urban as opposed to the rural area.

I
km ofthe consumers of heaith care.The majority of the In terms of acceptability this study shows low rates participants, 71%, stayed beyolid 5 km but at different . .
(e.g. the poor quality of the medical services).distances.
This finding n' eds further study, especially regarding a In this sample 2lU4 were lnelnbers of a medical aid furtl~er qualification of the perceived low quality of scheme, which is higher than the average of 11.3% in health care.Anvinam 11987:XIO) has shown that if the Northern Province.In this study a higher health services are not acceptable to consumers, they insufficiency of family doctors (84%) was found than will not be utilised even though they might be available and accessible.Acceptability or quality of health care was, in this study, in contrast to other studies not related to socio-economic status (Calnan, 1988:3 11).
From this study in line with Van Vuuren and Botes (19945) it appears that people without health insurance, along with those who consider their personal healtl~ to be poor, are of the opinion that health care services are less available (e.g.insufficierlt family doctors).Increasing age is associated with less availability, which is in contrast with the Bloemfontein study.This may be explained by the fact that in a rural area older people are less mobile to access health care services.
Participants of this study indicated an emphasis on medical health beliefs.This underlines the importance ofdoctors, especially for prevention and serious illness.In addition, the lack ofproper food and hygiene has also been identified as important reasons leading to illness.It is true that the area under study has problems with clean water supply.Differential health beliefs may have a significant relationship with different health providers like traditional healers, faith healers as compared with biomedical health care, andnot as found in this study when correlating biographic and attitudes towards bioi~~edical health care with health beliefs attributes (cf. Pillay, 199623).Illness attributes were not as expected related to any of the biomedical health services parameters.One would have expected that medical attributes to illness would be related to higher acceptability of biotlledical health care than supernatural attributes.In different studies (e.g.Pillay, 1996:4) it was found that people's health beliefs strongly influence their health andillness behaviour.
Limitations of the study are that the sample is restricted to a small geographic area and it was not stratified by age so that the findings cannot be generalised beyond the community and major age group uuder study.Furthermore, a more comprehensive -on the basis of qualitative research in the community under study - taxonomy can be developed to identify the components of quality ofhealth care.

CONCLUSION
The study found a low acceptability and quality of biomedical health care as perceived by lay persons in a rural South African community.A number of other factors like subjective evaluation ofpersonal health and not being member of a medical scheme, but not illness attributes influenced their attitude towards health services.
The success of strategies to revitalise primary health care services such as those advocated by the Bamako Initiative rests largely on their ability to meet the expectations of population, especially in ternls of quality.The evaluation of the quality perceived by the communities thus constitutes an important complement to the evaluations carried out according to the health authorities' own approaches.It is therefore important that primluy health care policy makers take cognisance of the existing differences like that of acceptability and affordability in attitudes toward biomedical health care.
The research provides valuable indications about tile changes that should be made to promote some areas of the quality ofprimary health care services.In the area of acceptability the role of interpersonal relations is ~mportant.As in other studies, the conduct ofthe nurses stands out as a central element of the judgement that users make about health services.Health services niust take note that their users want proper reception and treatment.Training may allow for the development or improvement of certain technical or even interpersonal skills.
Hildebrandt, E 1997: Have I angered my ancestors?

Harville Hendrix
Simon & Schuster of Australia Pty Ltd.Sydney Dr Harville Hendrix is one of the world's leadlng marital therapists.He began his career as a therapist counselling both individuals and couples.He mentioned that he felt competent and effective with individuals, but saw the marital relationship as a complex system and he was not always capable of dealing with couples effectively.He ended up doing what most therapists did: problem-orientated contractual marriage counselling.This approach was not always useful or effective.His interest in relationship therapy started out of his own despair and disappointment after his divorce, and he had a compelling desire to make sense out of his dilemma.
He did intensive research through professional books and journals, but couldn't find any meaningful discussions of marriage, or no comprehensive theory to explain the intricacies of the rnalelfemale relationship.To fill this gap he worked with hundreds of couples in private practice and thousands more in urorkshops and seminars.
Out of this research and marital therapy he developed a theory of marital therapy called Imago Relationship Therapy.The approach was electric.The divorce rate in his practice declined and the couples who stayed together reported a much deeper satisfaction in their marriages.
This book is about the theory and practice ofbecoming passionate friends.The book is divided into three parts.Part 1 focuses on "the unconscious ma~riage", an emerging psychological drama, that reveals all the hidden desires and automatic behaviours that are left over from childhood and form a leading source in creating marital conflict.
Part 2 explores the "conscious marriage" and helps you to satisfy your umnet childhoodneeds in positive ways.
Part 3 takes on all the ideas in Part 1 & 2, compiled into a unique ten week step by step course in relationship therapy.
This book can be very valuable to all advanced psychiatric nurse practitioners in the field in facilitating a more loving and supportive relationship in couples to promote their mental health.Sandra van Wyk, RN, DCur Lecturer, Department of Nursing Science; Rand Afrikaans University

Table 3
indicates health beliefs by differential attributes.Highest rates for health attributions were found for: (I) visiting a doctor for regular check-ups can prevent a person from getting sick; (2) people go to doctors when they are seriously ill; (3) people get sick because they do not eat proper foods or do not keep themselves clean;

Table 3 : Health belief questio1111aire (Agree=l, sometimes agree=2, disagree=3, not sure+)
HEALTH SA GESONDHEID Vol. 5 NO. 1 -2000 27.A person can become ill if they walk or cross over the path or spot , 20.Older people know a lot about illness and can advise other what to do 22.People get sick because they are lazy and do not work hard enough Van Vuuren, SJEJ & Botes, LJS 1994: Attitudes Influences of culture on health care with elderly towards health care in greater Bloemfontein.black South Africans as an example.