title: Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector.
abstract: BACKGROUND
  Early detection and effective case management of tuberculosis (TB) among a high-risk group of materially poor farm workers in an area of the Cape Winelands, South Africa, presents special challenges to the health community, where resource constraints lead to service reduction. In order to address this problem, local nurses established a collaborative partnership between permanent farm workers and their families, their employers, selected non-governmental organizations and the public health sector. In consultation with stakeholders, they developed an intervention primarily focusing on having peer selected trained lay health workers (LHWs) on farms, mentored and managed by nurses.
  
  
  OBJECTIVE
  To describe the complex process of implementation and evaluation of the LHW project, and provide a summary of a number of discrete studies evaluating the effectiveness, cost implications, and the perceptions and experiences of key stakeholders of the intervention.
  
  
  METHODS
  Quantitative and qualitative research methods conducted within the context of a pragmatic unblinded community cluster randomized control trial were used. Emphasis was placed on an iterative participatory interaction between the researchers and key stakeholders.
  
  
  RESULTS
  The intervention contributed to significantly better successful treatment completion rates among adult new smear-positive TB cases. The process implemented proved cost-effective and was pivotal in initiating a community-based social development programme.
  
  
  CONCLUSIONS
  The use of peer-selected LHWs within a wider programme of integrated care designed to merge technical biomedical approaches to disease management with more holistic social development activities, appears essential to meet the complex health needs in conjunction with public health of the rural poor.
authors.affiliation: Health Systems Research Unit, Medical Research Council of South Africa, Tygerberg, South Africa. judy.dick@mweb.co.za
authors.forename: J
authors.initials: J
authors.lastname: Dick
authors.forename: M
authors.initials: M
authors.lastname: Clarke
authors.forename: H
authors.initials: H
authors.lastname: van Zyl
authors.forename: K
authors.initials: K
authors.lastname: Daniels
mesh_terms: D000382:Agricultural Workers' Diseases / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D019090:Case Management / Q000458:organization & administration; D003152:Community Health Nursing / Q000458:organization & administration; D003150:Community Health Workers / Q000193:education / Q000458:organization & administration; D003159:Community-Institutional Relations; D003362:Cost-Benefit Analysis; D019468:Disease Management; D006302:Health Services Research; D006801:Humans; D007318:Inservice Training / Q000458:organization & administration; D007373:Interinstitutional Relations; D015403:Nursing Evaluation Research; D015404:Nursing Methodology Research; D011203:Poverty; D011320:Primary Health Care / Q000458:organization & administration*; D016730:Program Development; D015397:Program Evaluation; D036301:Qualitative Research; D012307:Risk Factors; D019035:Rural Health Services / Q000458:organization & administration*; D013019:South Africa / Q000453:epidemiology; D014376:Tuberculosis / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy