Pergamon

Soc. Sci. Med. Vol. 45, No. 1, pp. 149-157, 1997

PII: S0277-9536(96)00328-0

1997 ElsevierScience Ltd

All rights reserved. Printed in Great Britain
0277-9536/97 $17.00 + 0.00

WOMEN'S HEALTH STATUS A N D USE OF HEALTH

SERVICES IN A RAPIDLY GROWING PERI-URBAN AREA
OF SOUTH AFRICA
M. H O F F M A N , ~ W. M. PICK, 2 D. C O O P E R ' and J. E. M Y E R S ~
'Department of Community Health, University of Cape Town Medical School, Observatory, 7925,
South Africa and 2Department of Community Health, University of Witswatersrand, 1 York Road,
Park Town, South Africa
Abstract--Women's health in South Africa and particularly women living in peri-urban areas is being
influenced by three major factors. These include the political transition that is occurring in the country,
urbanization and the international interest in women's health. Changes in the delivery of health care to
the population, and in particular to women are being planned. It is therefore important that data are
available for the purpose of planning and evaluation of health services.
This paper describes a household survey in which 661 women were interviewed. Socio-demographic
patterns of women living in a rapidly urbanizing area were determined and related to health status, use
of health services and knowledge of the services.
Poverty appeared to be an overriding factor affecting the health of the population. One third of the
women were living in unserviced shacks. There was a high rate of unemployment and those who were
employed worked in low status jobs and earned very little. Rates of reported acute and chronic illness
were lower than described elsewhere in similar household interview surveys. A third of the acute illnesses were due to respiratory disease. Reported rates of diabetes and hypertension were low indicating
undiagnosed disease in the area. Being a member of an alliance household--a mixture of family, friends
and lodgers--was the main predictor of acute illness. For chronic disease, age and increasing educational status were the main predictors. Knowledge of services apart from those for cervical cancer
screening was good. The latter improved with increasing education, urbanization and being a member
of an alliance household.
As many of the women lived in unserviced areas and had little or no income the provision of infrastructural services and development programs are essential if their health is to be improved. The existing health services need to be developed to provide a comprehensive primary care service with special
attention being paid to the health of women. The service should be close to their homes and be affordable.
The information gathered in this survey will be used to plan services for women in the area and will
act as baseline data for evaluation. 1997 Elsevier Science Ltd

INTRODUCTION
This paper is concerned with the health status of
and use of health services by socially disadvantaged
women living in a rapidly growing peri-urban area
near Cape Town, South Africa.
The health status of women living in these areas
is being shaped by three factors, namely, the political transition in South Africa from apartheid to
democracy, rapid urbanization, and a growing
awareness o f the need for health care specifically
for women. These factors are briefly described
below.

Political transition

The apartheid policies of the Nationalist

G o v e r n m e n t of South Africa have resulted in the
health services o f South Africa being inequitably
distributed among various sectors of the population. There has been an emphasis on tertiary care
and the provision of some of the most technologically advanced hospitals and health care in the

world to a minority of the population. Primary care

services, particularly those in the rural and periurban areas, have remained undeveloped.
With the election of a new representative, democratic government, changes in the health care system are being introduced. The Reconstruction and
Development Programme (RDP) includes a complete transformation of the entire delivery system.
(Reconstruction and Development Programme,
1994). A National Health Service is being established which will be driven by a primary health care
approach. A key focus throughout the R D P is on
ensuring a full and equal role for women in every
aspect of the economy and society. Special mention
is made of the development of appropriate health
services for women. It is essential that public health
practitioners are able to provide policy makers with
information to plan services for the country.
Urbanization

In addition to the recent political transformation,

the population of South Africa is undergoing rapid
149

150

M. Hoffman et al.

socio-demographic changes. The global process of

urbanization has accelerated dramatically in South
Africa in recent years. In 1990 it was estimated that
approximately 22 million people or 63% of the
population lived in urban areas* and this is
expected to increase to nearly 33 million or 75% of
the population by the year 2000 (The Urban
Foundation, 1990). Urban growth mainly involves
the African~" population which is 75% of the total
South African population of 40 million people
(Race Relations Survey, 1992/93).
Over the past few years there has been growing
international recognition of urbanization as a major
determinant of health (URBIS, 1987). Urbanization
can result in advantages for health through access
to health care and improved infrastructure.
However, there are also many disadvantages, notably the exacerbation of poverty and the growth of
slum conditions.
In South Africa rapid urbanization, instead of
being a sign of economic progress, has become part
of the process of under-development leading to considerable urban poverty (Yach et al., 1990). These
environmental as well as socio-economic factors
have a profound effect on the population's health
status. The World Health Organization has classified the potential damaging effects of urbanization
in terms of poverty, industrialization and social
instability (Rossi-Espagnet, 1984).
When relating urbanization to health two different aspects of the process must be considered.
Firstly, there is the movement of people from the
rural to urban areas, resulting in a concentration of
the population and economic activities in cities.
Secondly, urbanization may be seen as a psychological and social process in which rural dwellers
adopt new ways of life (Fair, 1985). Women have
been identified as the most vulnerable group in a
rapidly urbanizing environment (Pick et al., 1990).
Little is known about the health status of these
women living in the peri-urban areas of South
Africa; there is also little data on their utilization of
health services and the information that is available
is scanty and unreliable. In addition, there is a paucity of data with regard to environmental or psycho-social factors. Information on these kinds of
issues, which may have a major effect on health status, is rarely available even in countries with efficient health information systems. As a result
planners are turning more frequently to household
surveys for information on health needs, and to
*Urban areas are defined as areas with high population
density with the absence of agricultural activity.
trace classification is according to the groups designated by the Population Registration Act which was
repealed in 1991. The groups were black or African,
coloured (people of mixed race), white and Asian
(mainly Indian). Under apartheid statistics were
recorded according to these groups and services were
allocated differentially.

assess the impact of health interventions (Hill and

Dollimore, 1991).
From September 1989 to February 1990, a community-based household interview study was conducted by a team of researchers in one of South
Africa's rapidly growing peri-urban areas,
Khayelitsha, in the Western Cape, The aim of the
study was to describe the socio-demographic
characteristics, household composition, social wellbeing and urbanization status of the women in the
area and to relate this information to health status
and use of health services by these women.

T H E STUDY AREA

Khayelitsha, which is situated 32 km from the

center of Cape Town, was established in 1983 and
.x
has become one of South Africa's most rapidly
growing peri-urban areas. In 1990 it was estimated
that half a million people live in the area (Harrison
and McQueen, 1992). Khayelitsha was established
with the idea of moving all African residents in the
vicinity of Cape Town to this area. This latter plan
was abandoned due to its impractical nature and
the changing political climate.
The study was conducted in a part of
Khayelitsha known as Town One, which had a
population of 200000.
Within Town One there are distinct areas. These
include a core house area with brick houses consisting of two rooms with flush sanitation and running
water; a site and service area where people are provided with a site, a tap and flush toilet, and build
their own home, usually a structure made out of
metal sheets, wood, canvas or plastic; a site and service area, where sewage removal was by bucket toilets and taps are shared by a number of
households; and areas of squatting where shacks
have been erected with no sanitation or services.
Health services in Khayelitsha
Public sector health services:. Preventive and promotive health services were provided for the area
by local authority clinics. These clinics are responsible for maternal and child health services, which
include immunization and family planning, and services for tuberculosis and sexually transmitted diseases. These services were provided free of charge.
Maternity services were provided at the Midwife
Obstetric Unit (MOU) by the obstetrical service of
a teaching hospital. The MOU with 10 beds was
the only maternity service for the whole of Khayelitsha. Curative services were provided by two
clinics, one of which remains open 24 hours a day.
At the time of the study patients paid on a sliding
scale according to their income with a minimum
rate of US$1.50. Immediately after the election of
the new goverment in April 1994 services for pregnant women and children under 5 were provided

Women's health status in South Africa

free of charge and recently free primary care services for all have been introduced.
Private health services:. There were 12 private
practitioners and a number of non-governmental
organizations (NGOs) providing services in the
area. Community health workers were employed by
some of these NGOs. Traditional healers worked in
the area but there was little information regarding
their services.

METHODS

A household interview survey was conducted.

Prior to conducting the survey a wide variety of
groups, organizations and individuals, including
health service providers in Khayelitsha were consulted. In-depth interviews were conducted with
key informants. The resultant data provided information about health services in the area and
the main health problems as perceived by the
key informants. In addition, this phase was helpful in developing the questionnaire and identifying local women who would be suitable
interviewers. Permission to conduct the survey
was obtained from community leaders in the various a r e a s .
A questionnaire was developed and translated
into Xhosa, the language spoken in the study area.
It was back translated into English to ensure reliability. A pilot study in which 47 women were
interviewed was conducted to test the questionnaire
and the logistics of the study.
The area was divided into 5 strata according to
the areas described earlier and a proportional random sample of 800 households was selected. A
household was defined as a group of people living
together and sharing household expenses. These
households were visited by one of 11 trained female
interviewers selected from the community. The
interview was conducted in Xhosa. A woman, over
the age of 15, who was considered by the household
to be the most senior and responsible woman was
interviewed. Contact was made with 722 of the 800
households selected. In 61 of these households there
was no woman resident. In all 661 women were
interviewed, giving a response rate of 89.4%.
Data on the following was collected."

(1) Socio-demographic data profile including

age, marital status, education, employment,
income, geographical area of residence and
household composition.
(2) Household composition, defined as one of
the following:

nuclear family: consisting of mother,

father and children
extended
family:
relatives
living
together

151

women only: women living on their

own or with children
alliance household: mixture of family,
friends and lodgers.
Urbanization. A complex variable indicating degree of urbanization was constructed by taking into account both
physical and psycho-social attributes.
These included place of birth, number
of years in an urban area, place that
the woman considered home, where she
would like to live when old, and ties
with the rural areas which included
having assets and close family. A score
was derived with 1 indicating rural, 3
indicating urban and 2 as transitional
(Appendix A). Cronbach's alpha = 6,
indicating that the score has good internal consistency.
Health status. Information was based
on self reports of episodes of illness
that had required use of services. An
acute illness referred to a condition
that had been present during the two
week period prior to the survey. A
chronic illness was defined as a condition that had been present for more
than three months.
Use of health services included service
used, method of transport to reach service, the cost of service and transport,
time taken to reach the service, and satisfaction with service.
Women's knowledge
of
services,
included information on where she
could have a child immunized, buy
milk for an infant, have tuberculosis
testing, have an injury treated, have a
cervical smear taken and receive help in
case of an emergency illness at night.

Data were analyzed using PC-SAS. Socio-demographic characteristics, household composition and
degree of urbanization were described using univariate analysis. The relationship of these characteristics
to health status, use of health services, and women's
knowledge of the various health services was determined using the Mantel-Haenszel X 2 test. Possible
confounding variables were controlled for using
multivariate analysis. Logistic regression models
were developed to measure the relationship between
socio-demographic variables and reported acute illness, reported chronic illness and knowledge as to
where to attend for cervical smears. Odds Ratios
with 95% confidence intervals were calculated. The
independent variables were defined for age: 45 and
over or less than 45 years; education: 5 years and
less or more than 5 years; urbanization: the urbanisation score was divided in two giving urban or

M. Hoffman et al.

152

rural; marital status: married, single, separated,

widowed or divorced; household composition: alliance or other categories.

RESULTS

Socio-demographic variables (Table 1)

O f the 661 women interviewed 31% lived in
unserviced sites, that is dwellings without water or
sanitation, while 13.7% lived in the formal housing
area, and 54.6% in site and service areas.
The population of women was relatively young
with ages ranging from 15 years to 75 years and a
median age of 33 years. Only 15.3% were over the
age of 45 years.
Marital status were as follows: 60.2% were married, 28.4% were single, and 11.3% were either
widowed, separated or divorced.
Seven percent of respondents had no formal
schooling, 16.5% were functionally illiterate, having
completed less than 5 years of formal education,
and 54.3% had some secondary school education.
O f the 361 women who were employed, the majority i.e., 60.7% worked in the formal sector. O f
these 66.2% were in domestic service. The main
area of employment for the 148 working in the
informal sector was trading, of which the major
form was hawking. In addition 22% of women
reported running shebeens*. Six women reported
working in both the formal and informal sector. O f
the 300 who were unemployed, 64.7% were work
seekers and the remaining 35.3% were voluntarily
unemployed. Those not seeking work gave reasons
such as pregnancy, looking after an infant, illness
or disability, or in 17.2% of cases, the fact that
their husbands or relatives would not allow them to
work. Only seven women reported that they preferred not to work.
The income of 75% of all the employed women
was less than US$120/month,t with women who
worked in the informal sector reporting an irregular
income.
According to the score calculated for the degree
of urbanization, 35.6% of women were characterized as urbanized, while 27.4% were rural, and
37% transitional.

Health status
Fifty-one (7.7%) of the women reported having
had an acute illness which had required them to
visit a health service within the 2-week period prior
to the survey. A third of the illnesses were due to
*Shebeens or taverns are drinking houses, which have
recently been legalized.
tCalculated according to the 1 9 9 3 rand/dollar
exchange of 3:3/1. The household subsistence level
given by the South African Institute of Race relations
is US$240/month.

respiratory tract infections which included tonsillitis, bronchitis, asthma, cough and flu.
The reported acute illness was significantly associated with age (p = .022), and so were marital status
(p = .017), household composition (p = .028), and
degree of urbanization (p = .052). There appeared
to be an increase in the reported acute illness as age
increased, if the woman was divorced, widowed or
single, if the household composition was that classified as alliance, or if the woman was more urbanized. However when controlling for age, marital
status and urbanization were no longer significant,
but alliance households (as defined in the methods
section) remained significantly associated with ill
health. Acute illness was not related to educational
status or employment.
Thirty three (4.9%) women reported chronic illness which had been present for more than three
months and had resulted in a visit to the health service. There were 14 cases of reported hypertension,
giving a prevalence of 2.2%. The next most common condition was diabetes with a prevalence of
0.5%. Only two cases of tuberculosis were reported.
Chronic illness increased significantly with age
(p = .000) and was significantly related to house-

Table 1. Socio-DemographicCharacteristics
Characteristic

No.

120
250
190
68
33

18.2
37.8
28.7
10.3
5.0

398

60.2

188
75

28.4
11.4

46
63
193
355

7.0
9.5
29.5
54.3

219
148

33.1
22.5

300

45.4

145
29
19
26

66.2
11.9
8.7
11.9

88
23
22
6
5
4

59.5
15.5
14.9
4.0
3.4
4.0

1-60

154

46.5

60-11
120+

125
52

37.8
15.7

Age in years
15-24
25-34
35-44
45-54
55+
Marital status
Married/living
together
Single
Divorced/separated/
widowed
Educational status(yrs
schooling)
Nil
1-4 yrs
5-7 yrs
8-12 yrs
Employment status
Formal employment
Informal sector
employment
Unemployed
Area of employment
(formal sector)
Domestic service
Teaching/nursing
Manufacturing
Other
Area of employment
(informal sector)
Trading
Handicrafts
Shebeens
Hair dressing
Traditional healing
Other
Income ($/mth)

Women's health status in South Africa

153

Table 2. Odds ratios of women who reported acute and chronic illnesses
Acute illness

Chronic illness
95% CI

Variable

OR

95% CI

OR

Age
(>45yrs/ < 45yrs)
Education
(<5yrs/> 5yrs)
Marital status
(Married/
sing,sep,wid,div)
Household
composition
Alliance/others

2.3

(1.1-4.6)

6.5*

(2.7-14.5)

1.2

(0.7-2.2)

0.4*

(0.16-0.9)

0.8

(0.4-1.8)

1.I

(0.4-2.6)

2.5*

(1.1-5.6)

1.2

(0.3-4.1)

hold composition (p = .003). M o r e women living in

alliance households reported chronic illness than
did women living in nuclear or extended households. W o m e n who were more educated or more
urbanized reported more illness. Chronic illness was
not associated with marital status or employment
status.
Logistic regression analysis is shown in Table 2.
Household composition (alliance families) was the
strongest predictor of acute illness (OR = 2.5). F o r
chronic illness, age ( O R = 6.5) and educational
level (OR = 0.4) were the strongest predictors.

Use of services
When women were asked which health service
they would be likely to attend in case of illness,
17.2% responded that they would use private services and 82.8% public services. Use of private services appeared to increase with age but this was not
significant. It was however significantly related to
marital
status
(p = .012)
and
employment
(p = 0.046). Many more married women would use
private services than single women, and similarly
with women who were formally employed. Intended
use of private versus public services was not related
to educational status or household composition.
When women were asked which service they had
used for the last episode of acute illness, 29.8%
reported that they had used a private service and
70.2% had used a public service. Use of the private
sector services appears to be associated with
increasing age, higher educational status and formal
employment. W o m e n who were married were more
likely to use the private services as were women
who were less urbanized. No tests were significant,
possibly due to the small numbers.
When women were asked about the service they
had used for chronic illness, 6.3% reported private
and 93.8% public. This was significantly related to
age (p = 0.021), with more older women using the
public services. As the numbers attending the public
service were small there were no statistically signifi*Taxi in this instance is different to the conventional type.
They are mini-vans that pick up numerous people
along special routes. It is a relatively cheap form of
transport.

cant associations with service use for chronic illness

and socio-demographic and urbanization variables.
Less than 3% of persons reported using a traditional healer.
Most women (45.1.%) used a taxi* or walked
(35.4%) to reach the health service for acute illness.
When using the services for chronic illness 63.6%
used a taxi, and 13.3% walked.
The time it took for women to reach the health
service was similar in the case of acute and chronic
illness. Approximately 50% took less than half an
hour. Seventeen percent took between 1-2 hours
and 2.3% more than 2 hours.
Forty-five percent of women did not pay for
transport, 23.8% paid less than US$1, and 2% paid
more than US$3.
When using services for acute illness 12.5% did
not pay, 56% paid less than US$1 and 30% paid
more than US$3. For chronic illness, 12.5% did not
pay, 78.1% paid less than US$1 and 6.3% paid
more than US$3.

Attitude regarding service

When asked whether they were satisfied with the
service they had received, 92.3% replied in the affirmative.

Knowledge of health services (Table 3 and Table 4)

Most women knew where they should go for certain services. More than 89% knew where to go for
immunization, to buy milk for an infant, for treatment of a child with diarrhea, for a tuberculosis
test, for an injury or for illness at night. However
33.9% did not know which service they should use
for cervical smears. Lack of knowledge was associated with age (p = .007) with the youngest and oldest women having the least knowledge. A higher
educational status, and a higher degree of urbanisation was associated with knowledge as to where to
attend for cervical smears (p = .002).
A logistic regression model confirmed that age
(OR = 0.5), level of education (OR = 0.7), degree
of urbanization (OR = 2.0), and alliance households (OR = 2.0) were significant predictors of
knowledge of the services.

M. Hoffman et al.

154

Table 3. Knowledgeof Health Services

Don't know
Immunization of
child
To buy milk
Child with diarrhoea
Test for tuberculosis
Pap test
Injury

Know

No.

No.

42

6.4

619

93.4

57
40
52
224
64

8.6
6.1
7.9
33.9
9.7

604
621
609
437
597

91.4
93.9
92.1
66.1
90.3

DISCUSSION

Health status

The prevalence of both reported acute and

chronic illness was lower than that described in
other community based studies (Kroeger, 1983;
Office of Population Census, 1985; Nchinda, 1977).
A number of factors may have contributed to this
low rate. The method of data collection may have
had a major influence on the results as only illness
that required a visit to the health service was
reported.
The difficulty of measuring health status is well
recognised and reported by many authors (Jette,
1980). In spite of many methodological problems
the household interview survey is the most extensively used measure in both developed and developing countries (National Centre for Health Statistics,
1975; United Nations, 1984; Kohn and White,
1976; Kroeger, 1983). Kroeger (Kroeger, 1985),
reviewing a number of papers, reported that having
a time period recall related to the condition e.g., 2
weeks for acute conditions and reporting contact
with the health service was adopted by many studies as a compromise between obtaining enough information and loss of accuracy due to vagaries of
memory.
In addition to these methodological problems it
is possible that poor quality of care and problems
of access to health services were major issues. Many
women had to travel some distance to reach the service as the rapid extension of Khayelitsha has
resulted in public services being out of walking distance for a large proportion of the population.
These factors would particularly affect use of service for screening for disease or treatment of
chronic illness, as the latter requires regular visits.
The fact that many of the women with little or no
income had to pay for the service and transport to
the service is likely to be a major deterrent to the
women using the service. Women in the study may
have failed to recognize illness. Educational level,
which has been shown in other studies to be related
to recognition of illness (Koblinsky et al., 1993),
was in this study a strong predictor of chronic illness. The youthfulness of the women may account
for the overall low rate and pattern of reported illness. Respiratory disease was the main reason for
attending the health service. This latter finding may

be a result of the poor housing conditions in which

most women live.
Significantly more acute illness was reported in
alliance households. This may be related to the fact
that women in these households tend to be older
than women in nuclear or extended families, that
there is a higher proportion of single, separated,
widowed and divorced women, and that these
households tend to be more economically disadvantaged than nuclear or extended families. This explanation does not however account for the differences
in reported acute illness between alliance and
woman-headed households, which tend also to have
older women and be more economically disadvantaged. Using logistic regression to control for other
factors, it was found that being a member of an
alliance household remained a predictor of acute illness. It is possible that conditions in the alliance
households are overcrowded, resulting in more ill
health. The high proportion of alliance and womanheaded households is evidence of changes in the traditional family structure and of the social changes
occurring in rapidly growing peri-urban areas
(Koblinsky et al., 1993).
The apparent undiagnosed disease in this community is confirmed by studies in which persons were
examined. In a recent study conducted in the
Western Cape, which measured blood pressure in
the African population, an overall prevalence
among women in the 16-64 year age group was
found to be 8.9%, as compared with 2.2% reported
by women in this study (Steyn et al., 1991). This
finding is similar to that of other community-based
studies in which fewer than half the cases of hypertension in the community were diagnosed (Banaan
et al., 1981). Similarly the reported rate of diabetes
was much lower than the rate of 6% based on glucose tolerance tests in a study conducted among
Africans in the Western Cape (Levitt et al., 1993).
Only two cases of tuberculosis were reported. This
is slightly lower than the 3-4 cases one would
expect if extrapolated from the official figure for
this area of 541/100000 (Harrison and McQueen,
1992). The latter figure is based on cases notified to
the local authority and is an under-estimate of the
true rate. This confirms the view that there are
100000 new cases of tuberculosis in South Africa
each year, of which only 80000 are notified
(Glathaar, 1985).

Women's health status in South Africa

Table 4. Odds ratios of women'sknowledgeof servicesfor cervical smears
Variable
Age
(>45 yrs/ < 45yrs)
Education
(<5yrs/> 5yrs)
Marital status
(Married/single,sep,wid,div)
Household composition
Alliance/others
Urban/rural

Knowledgeof servicesfor cervical

smears
OR
99%CI
0.5*

(.3~).8)

0.7*

(0.5-0.9)

0.8

(0.5-1.3)

2.0*

(1.0-3.8)

2.0*

(1.4-2.9)

*p < .05.

Use o f service
Although most women used public services many
more women attended private services for acute illness than said they would when they had been
asked which health service they would attend. This
is probably because acute illness requires immediate
intervention and the public health services are not
always available. With chronic illnesses, there is
more time to plan the visit and this probably
accounted for the higher usage of public services
for chronic illnesses. In addition, a chronic illness
would require repeated visits which would be prohibitively expensive if private practitioners were used.
Women who were married, more educated, and in
formal employment were more likely to attend a
private health service. Surprisingly, less urbanized
women were also more likely to use private health
services. It is unclear why this is the case--it is
possible that less urbanized women have less information about services on which to base their
choices.
It is unlikely that the stated high rate of satisfaction with the services is an accurate reflection of
women's attitudes as shortly after the completion of
the study women staged a protest at the local day
hospital demanding better services (Harrison and
McQueen, 1992). Similarly, the reported rate of use
of traditional healers is lower than one would
expect, and is likely to be inaccurate. Both issues
are sensitive, and the respondents may have been
tempted to provide answers they thought would be
approved of by the researchers. A qualitative study
designed to explore these issues in depth, and to
take into account the need to gain the trust of
informants, would probably be more successful in
obtaining accurate data.

Knowledge o f services
Women in Khayelitsha appeared to have good
knowledge of the services available, with the exception of the service for cervical smears. However, the
fact that they know about services does not necessarily mean that they use them. This is the case with
regard to immunization: in spite of women knowing

155

where children should be immunized, coverage is

approximately 60% (Yach et al., 1990, 1990a).
The lack of knowledge about cervical smear services is particularly worrying as cancer of the cervix, a disease which can be prevented, is common in
African women. Twenty-five percent of registered
cancer deaths among African women are caused by
this disease (Bradshaw et al., 1984; Bailie, 1993).
Older, less educated, and less urbanized women,
who have been shown to be most at risk, also had
the least knowledge. However, women living in alliance families had better knowledge than those in
nuelelr or extended families or women-only households. The reason for this is not clear. It may be
that in alliance households the women have contact
with a variety of people who share knowledge.

Relationship to urbanization
One of the key objectives of this study was to
examine the relationship between urbanization and
the health of women in Khayelitsha. No clear relationship was however found between the degree
of urbanization, as measured using a composite
variable, and health status or use of services. The
only significant finding was that women's knowledge of which service to attend for cervical cancer
screening increased with urbanization. This apparent lack of relationship may be due to several factors. Firstly, the measurement of urbanization is
extremely difficult and under considerable debate
(Yach et al., 1990). In other studies where a single
variable, such as length of stay, place of birth or
place considered to be home, was used as an indicator of urbanisation, relationships were demonstrated (Pick, 1991; Koblinsky et al., 1993; Levitt et
al., 1993; Cooper, 1995). In this study a composite
variable was constructed in an attempt to measure
the psycho-social as well as the physical effects of
urbanization. Cronbach's alpha was equal to 6, indicating good internal consistency and validity.
There is need for further in-depth research to determine the most appropriate measures of urbanisation.
A second factor which may account for the lack
of relationship between urbanization and health is
that there may have been insufficient exposure of
the women to the urban environment for it to have
had an influence on their health. It is possible that
the effects of urbanization may only be detectable
after generations rather than years.
Thirdly, it is possible that the effects of urbanization were masked by the overriding poverty prevalent in Khayelitsha. Many women lived in
unserviced areas without adequate shelter, water
and sanitation. In addition many were poorly educated, unemployed, or employed in low-status jobs
with very low incomes. These factors all have major
implications for the health status of the population
(Nchinda, 1977).

156

M. Hoffman et al.

Implications for policy and planning

In this study a third of women were living in
unserviced shacks and many of the women were
unemployed, illiterate, and impoverished. It is thus
essential that in addition to developing health services, basic infrastructural services, such as clean
water, sanitation, electricity and housing must be
provided and comprehensive social development
programs are needed. The new ANC government
has recognized this and is planning to provide housing and electricity to all South Africans and develop
opportunities for education and employment ~Cape
Times, 1993).
The health services which currently exist in
Khayelitsha are clearly inadequate. For example,
nearly half of the women interviewed had to travel
more than half an hour to reach the health services.
Costs of transport and services had to be borne by
the women, the majority of whom had little or no
income. In addition there was only one physician
available to serve half a million people at night. As
women are the main users of the health service
either for themselves or their children (Verbrugge,
1985), health services that offer quality care, that
are accessible both in distance and time and affordable to the women need to be developed. It is important that, in planning the development of the
health services, issues of accessibility (both distance
and convenience of hours) and affordability be
taken into account. The new government, immediately after coming into power, introduced free services for children and pregnant women. As from
June 1996 free primary health care services for all
has been introduced. The details of the practical
provision of this services are still being discussed. It
has been recognized by The World Bank that provision of essential services for women confer widespread economic and social benefits which are of
sufficient importance and impact to justify public
monies (World Bank, 1994).
There was a high rate of undiagnosed chronic
disease among the women and knowledge of emergency and child services was far greater than knowledge of women's preventive services. It is thus
important that the essential services should have an
emphasis on prevention, providing health education
programs. These programs, as well as providing
women with information concerning their health,
should provide them with information as to the services they should attend. Screening services for
chronic disease such as cancer of the cervix, hypertension and diabetes must be readily available so as
to identify early unrecognized disease. In addition,
so as to prevent complications, adequate treatment
for early chronic disease must be provided.
Services need to be not only affordable and accessible, but also considered to be appropriate by the
women they serve. To this end, the health services
must ensure privacy, confidentiality, and respect.

This last fact is extremely important in redressing

the multiple oppressions that these women have
been subject to. Ideally, women should be participants in the process of planning appropriate health
services.

CONCLUSION
The provision of health services within the
rapidly-growing peri-urban areas of South Africa
will be effective only if basic infrastructural services
are provided, and development on a broad, societal
level occurs. Given the extensive poverty of residents in these areas, health services will have to be
free or extremely cheap. The health services inherited from the Nationalist Government are fragmented and lacking in equity; there is need to develop
the services that do exist and create services where
there are none. Comprehensive primary health care
services must be provided for the total population.
More specifically, services must be provided for
women. The emphasis and direction of women's
health services must be changed from a narrow
focus on controlling fertility to a broader focus on
reproductive and general health, with an emphasis
on promotion and prevention. The information
gathered in this study will contribute towards the
development of a model women's health service in
Khayelitsha. The data will act as a baseline for
evaluation.

UNLINKED REFERENCES

Department of Obstetrics and Gynaecology, 1992

Acknowledgements--We wish to thank the National

Urbanization Programme of the Medical Research
Council of Southern Africa for financial support and collaboration, the interviewers for their assistance in conducting the study and Dr M. Reich and Dr G. Wyshak of the
International Health Department at the Harvard School
of Public Health for their invaluable assistance in the
analysis and the writing up of the report.

REFERENCES

Bailie, R. (1993) Towards a rational cervical cytology

screening strategy. Dissertation, Faculty of Community
Health, College of Medicine of South Africa.
Banaan, L. T., Beevers, D. G. and Jackson, S. H.
D. (1981) ABC of blood pressure management.
Detecting hypertensive patients. British Medical Journal
282, 1211-1213.
Bradshaw, D., Botha, H., Joubert, G., Pretorius, J. P.,
van Wyk, R. and Yach, D. (1987) ,4 Review of South
African Mortality (1984). Medical Research Council,
Parow, South Africa.
Cooper, D. (1995) Women's social position and their
health: a case study of the social determinants of the
health of women in Khayelitsha, Cape Town, South
Africa. Ph.D. thesis, Department of Community Health,
University of Cape Town.

Women's health status in South Africa

Fair, T. D. J. (1985) The urbanization process in
South Africa. RSA 2000. Dialogue for the Future 7(1),
1-6.
Glathaar, J. (1985) Tuberculosis: Basic Perspectives.
Medical University of Southern Africa, Cape Town.
Harrison, D. and McQueen, A. (1992) An Overview of

Khayelitsha: Implications for Health Policy and Planning.

Medical Research Council, Parow, South Africa.
Hill, A. and Dollimore, N. (1991) Assessing the impact of
health programs using household surveys in Mali.
Health Policy and Planning 6(4), 336-367.
Jette, A. M. (1980) Health Status Indicators. Their utility
in chronic disease evaluation research. Journal of
Chronic Disease 33, 567-579.
Koblinsky, M., Timyan, J. and Gay, J. (1993) The Health
of Women--A Global Perspective. Westview Press,
Oxford.
Kohn, R. and White, R. L. (1976) Health Care: An
International Study. Oxford University Press, London.
Kroeger, A. (1983) Health interview surveys in developing
countries: a review of the methods and results.
International Journal of Epidemiology 12, 465-481.
Kroeger, A. (1985) Response errors and other problems of
health interview surveys in developing countries. World
Health Statistics Quarterly 38(1), 15-37.
Levitt, M. S., Katzenellenbogen, J. M., Bradshaw, D.,
Hoffman, M. and Bonnici, F. (1993) The prevalence
and identification of risk factors for NIDDM in urban
Africans in Cape Town, South Africa. Diabetes Care
16(4), 601-607.
National Centre for Health Statistics (1975) Health
Interview Survey Procedure 1957-1974. Vital and Health
Statistics Series 1, No. 11. NCHS, Rockville, MD.
Nchinda, T. C. (1977) A household study of illness prevalence and health care in rural district of Cameroon.
International Journal of Epidemiology 6, 224-235.
Office of Population Census on Surveys, Social Survey
Division (1985) General Household Survey 1983. HMSO,
London.
Pick, W. M. (1991) Urbanisation, household composition
and women's health in a peri-urban area in South
Africa. [Unpublished]. Takemi Program, Harvard
School of Public Health, Boston, MA.
Pick, W. M., Hoffman, M., Myers, J. E. and Klopper, J.
M. L. (1990) Women's health and urbanisation. South
African Medical Journal 77, 553-554.
Press report, Cape Times. May 1993.
Race Relations Survey 1992/93 (1993). South African
Institute of Race Relations, Johannesburg.
Reconstruction and Development Programme (1994) A
Policy Framework African National Congress. ABC
Printers, Cape Town.
Rossi-Espagnet, A. (1984) Primary Health Care in Urban
Areas: Reaching the Urban Poor in Developing
Countries. WHO/UNICEF report SHS/84.4.
Steyn, K., Jooste, P. L., Bourne, L., Fourie, J.,
Badenhorst, G. J., Bourne, D. E., Langenhoven, M.,
Lombard, C. J., Truter, H. and Katzenellenbogen,
J. (1991) Risk factors for coronary heart disease in the

157

black population of the Cape Peninsula. The BRISK

study. South African Medical Journal 79(8), 400-405.
The Urban Foundation (1990) Policies for a New Urban
Future. Urban Debate 2010, No. 1 Population Trends.
United Nations (1984) Studies in method. In Handbook of
Household Survey, health section. Series F, No. 31.
United Nations, New York.
URBIS (1987) Urbanisation in Africa, 1986/87, Vol.4.
Oxfam, Oxford.
Verbrugge, L. (1985) Gender and health: an update on hypotheses and evidence. Journal of Health and Social
Behaviour 26(3), 156-182.
World Bank Report (1994) Women's Health and Nutrition:
Making a Difference. Population Health and Nutrition
Department, World Bank, Washington, DC.
Yach D., Coetzee N., Hugo-Hamman C. T., Fisher, S. A.
and Kibel, M. A. (1990) Identifying children at risk in
peri-urban Cape Town. South African Journal of
Epidemiology and Infections 5(1), 6-8.
Yach D., Matbews C. and Buch E. (1990) Urbanisation,
health: methodological difficulties in undertaking epidemiological research in developing countries. Social
Science & Medicine 31(4), 507-514.

APPENDIX A

Urbanization Score
This was calculated incorporating the following physical
and socio-psycho factors:
(1)
(2)
(3)
(4)
(5)
(6)

Place of birth
Place considered home
Place where they would like to live when old
Assets in the rural area, house, livestock
Close relatives in the rural area, spouse, children
Number of years in the urban area were divided
into 4:

less than 5 years = 1

6-10 years = 2
11-19 year = 3
20+ years = 4

If 1, 2 or 3 was an urban area the score = 1, if rural the

score = 0
If for 4 or 5 there were no assets or relations in the rural
area the score = 1, if there were the score = O.
An urbanization score was obtained by adding the scores
of questions 1-5 and multiplying them be either 1, 2, 3 or
4 depending on the number of years spent in the urban
area.
This overall score was divided into three with the lowest
third being considered rural, the middle third transitional
and the upper third urban.
Cronbach's alpha = 0.6 was calculated indicting good internal consistency.