Survey with MMR remains as one of the most important methods available for measuring the size and extent of tuberculosis, specially in developing countries. Its value in case-finding programmes is well recognised. Nevertheless, mass miniature radiography with a single picture of the chest has a wide margin of error owing to the intra & inter-individual differences in X-ray reading. A study was undertaken to know the errors involved by repeating an X-ray picture after an interval of 3 to 4 months and judging the first picture in the light of a comparative reading of the two pictures. It is postulated that two pictures taken at an interval, may afford better judgement regarding the assessment of a case than a single picture only. A prevalence survey was carried out in Tumkur district in 1960-61, among 62 villages and 4 towns; 20 villages were selected for this study. A total of 8,000 persons were registered, 5,300 of them were X-rayed and re-read by two readers. Photofluorograms were repeated after three and a half months after the first picture. At the time of repeat X-ray, a spot sample of sputum was collected from persons with abnormal shadows.

Briefly the findings of the study were: (1) About 20% of bacillary cases were among those with inactive or non- tubercular shadows on the basis of a single X-ray film. (2) Inter-individual agreement for X-ray active cases was of the order of 50%. (3) Intra-individual agreement for X-ray active cases was 52% for one reader and 69% for the two readers. (4) Mass miniature radiography with a single film, in spite of its inherent limitations, is the best available method both for surveys as well as for case-finding programmes due to its ability to find cases as well as potential cases in a short time. (5) Even the agreement between two sputum samples collected within an interval of 1-3 days was 42% for positive results.

Studies on the distribution of tuberculous infection and disease in households have mostly been restricted to the examination of contacts of known cases. Clinical experience has lead to a strong belief that tuberculosis is a family disease and contact examination is a “must” for case-finding programmes. A representative picture of the distribution of infection and disease in households can be obtained only from a tuberculosis prevalence survey.

This paper reports an investigation, based on a prevalence survey in a rural community in south India. The survey techniques and study population have been described in an earlier report. Briefly, the defacto population was given a tuberculin test with 1 TU of PPD RT 23 with Tween 80 and those aged 10 years and above were examined by 70mm photofluorography. All the X-ray pictures were read by two independent readers. Those with any abnormal shadows by either of the two readers were eligible for examination of a single spot specimen of sputum by direct smear and culture. The defacto population numbered 29,813 and tuberculin test results were available for 27,115. After excluding BCG scars, the study population of 24,474 was distributed over 5,266 households which were further classified as “bacillary case household” with atleast one bacteriologically confirmed case, “X-ray case household” with atleast one radiologically active case but with no bacillary cases and ‘non-case household’ with neither a bacillary nor an X-ray case. Total bacillary cases were 77 and were distributed in 75 household. 74 households had one case each and one household had 3 bacillary cases.

The findings of the study have thrown considerable doubt on the usefulness of contact examination in tuberculosis control; (1) over 80% of the total number of infected persons, in any age group, occurred in households without cases, (2) cases of tuberculosis occurred mostly singly in households, and the chance of finding an additional case by contact examination in the same household is extremely small, (3) a common belief has been that prevalence of infection in children in 0-4 age group is a good index of disease in households, but in this study about 32% of households with cases of tuberculosis had no children in this age group, (4) in houses with bacteriologically confirmed case only 12% of the children in 0-4 age group showed evidence of infection, a possible explanation of such a low intensity of infection could be that there is resistance to infection. It is well known that some children even after repeated BCG vaccination do not become tuberculin positive. It is felt that a large number of children do inhale tubercle bacilli, but a primary complex does not develop or even if it develops, the children remain tuberculin negative. A hypothesis has been made that in addition to resistance to infection, there is something known as “resistance to disease”. Otherwise, it is difficult to explain why under conditions of heavy exposure in infection, only some individuals develop evidence of infection and very few develop disease thereafter.

The prevalence and incidence rates of tuberculous infection and disease in the community are known in the age group 10 years and above from several surveys carried out so far. The present paper provides various parameters of tuberculosis in particular in the pediatric age group. A random sample of 119 villages in 3 taluks of Bangalore district were surveyed 4 times from May 1961 to July 1968 at intervals of 18 months, 3 years and 5 years of the initial survey. Tuberculin test was done for the entire available population with 1 TU PPD RT 23 with Tween 80, and 70mm X-ray for all available persons aged 5 years and above. Two samples of sputum were obtained from the X-ray abnormals, and examined by smear and culture.

It was found that prevalence of infection increased with age from 2.1% at 0-4 year age group to 16.5% at 10-14 year age group, compared to 47% at 15 years and above age group. Prevalence of disease in 5-14 year age group was considerably lower than in age group 15 years or more. Tuberculosis morbidity increased with the size of tuberculin reaction and it was high among children with reaction 20mm or more. Incidence of infection increased with age from 0.9% per year in age group 0-4 years to 2.8% per year among that of 15 years and above. Incidence of disease also showed the same phenomenon-, rising from 0.5% in age group 5-9 to 4% per year in the age group 15 years and above. There were 10 sputum positive cases in 5-14 years of age in first survey, of them, 8 became negative and one died. While from among 152 cases in 15 years and above age group, 48 became negative, 72 died and 32 remained positive. The fate of cases of pulmonary tuberculosis in 5-14 years age was not as serious as in 15 years and above age group. The survey had no means of examining miliary and meningeal tuberculosis.

Children as well as adults with larger reaction of 20mm or more to tuberculin test had higher mortality. This could be considered due to tuberculous infection after taking into account death due to non- tuberculous reasons in both the infected and uninfected groups. Use of chemoprophylaxis might be considered for those who give history of contact with open cases and have tuberculin reaction size 20mm or more.

Available data from longitudinal study (1961-68) from several different situations have been reviewed to understand the significance of patients showing radiological evidence of pulmonary tuberculosis without bacteriological confirmation. SITUATION IN GENERAL POPULATION: Few of the smear negative but X-ray active tuberculous patients (suspect cases) found in a survey of rural population done by National TB Institute, were culture positive (7-10%). On follow up for 18 months, only 3% of them became culture positive under conditions where intervention with specific treatment was absent or minimum. It is thus concluded that most of the cases diagnosed as active tuberculosis on the basis of single X-ray are not likely to be cases of tuberculosis. SITUATION AMONG SYMPTOMATICS ATTENDING HEALTH INSTITUTIONS: Data from the State TB Demonstration and Training Centres (STDTC) and the District Tuberculosis Programmes (DTP) have been presented. The New Delhi Tuberculosis Centre records (1970) show that only 27% of microscopy negative radiologically positive patients were confirmed on culture. For Bangalore and Agra STDTC, the proportions so confirmed were 20% and 25% respectively. It has been calculated that in the DTPs, not more than 30% of the microscopy negative radiologically positive patients could be the real cases of tuberculosis. In the DTP situation not more than 10% of the suspect cases may develop bacteriologically confirmed disease. Thus, not many of the suspect cases could be real cases of tuberculosis either on the basis of confirmation by culture or on the basis of development of bacteriologically positive disease in future.

Are the cases diagnosed ‘early’ by radiology? The hypothesis that X-ray discovers cases in the early stages has not yet been put to a scientific test. Further, the large differences even between experienced readers in interpreting X-ray shadows, render the method of X-ray diagnosis questionable. Is anti tuberculosis treatment of suspect cases warranted? The possible advantage of considering treatment of suspect cases as chemoprophylaxis has to be weighed against conservation of resources for treatment of infectious cases and the possible harmful effects of anti TB drugs to persons who are not suffering from tuberculosis.

The study was undertaken among 22,957 persons belonging to 55 randomly selected villages of Nelamangala taluk of Bangalore district in 1975, to find out precise estimates of prevalence of bacillary disease. Symptom screening was done by well experienced social investigators, according to a brief interview schedule. Sputum was collected from all above the age of 5 years reporting chest symptoms for seven or more number of days during the previous two months. Within two weeks after symptom questioning, all were tuberculin tested and all 5 years and above were X-rayed. Additional sputum collection was done for those asymptomatics who had abnormal shadows in their chest X-rays.

The overall prevalence rate of culture confirmed bacillary cases by symptom and/or X-ray screening was 0.32 percent. Same prevalence was seen with X-ray alone also. But the overall prevalence rate based on symptom screening alone was 0.21 percent which is significantly lower than that of symptom and/or X-ray screening, or X-ray screening alone. The prevalence rates by age and sex based on symptom screening were about two-thirds that of rate based on X-ray and/or symptom screening. Hence to obtain prevalence rate according to X-ray and/or symptom screening, a correction factor of 1.52 should be applied to the prevalence rates obtained by symptom screening alone. This correction factor is fairly good for most of the age groups. It was also estimated that the cost of surveying the population by symptom screening alone is about half that of surveying the population by X-ray screening.

The data from a longitudinal survey conducted in Bangalore district from 1961-1968 by National Tuberculosis Institute was analysed to find out the prevalence, incidence and fate of suspect cases. In brief, the survey was conducted in 119 randomly selected villages in three taluks of Bangalore district and repeated within the next five years. At each survey, eligible population was subjected to tuberculin, X-ray & sputum smear and culture examinations.

The overall prevalence rate of suspect cases among persons aged five years and more was 1.06% at I survey, 0.68%, 0.49% and 0.43% at II, III and IV survey respectively. In males, the prevalence rate was 1.19% at I survey & 0.62% at IV survey corresponding figures for females were 0.94% and 0.24% respectively. A decline of prevalence of suspect cases from 1.06% at I survey to 0.43% at IV survey was observed. The overall incidence of suspect cases was 0.16% between I & II surveys, 0.10% between II & III, and 0.06% between III & IV surveys. The overall as well as age specific annual incidence rates between III & IV surveys were significantly less than that between I & II surveys. At all the three intervals the incidence increased with the age. Incidence of suspect cases in males was more than that in females. Change in disease status over a period of time is termed as "fate". The disease status was classified as (i) cure (ii) continued to be suspect case (iii) converted into bacillary cases and (iv) dead. The percentage of cure (51.9%, 53.2% and 50.3%) and conversion into bacillary cases(7.2%,5.8% and 5.4%) were almost the same at all the three intervals. But the percentage of those who remained suspect cases reduced from 33.5% at the end of 18 months to 17.5% at the end of 60 months. On the other hand, the death rate increased from 7.4% at the end of 18 months to 26.8% at the end of 60 months. The decreasing trend of continuing to be suspect cases at the rate of 10% between two observations, appears to be corresponding to the increasing trend in the death rate as seen from the observations made at the three intervals.

Material from a community survey carried out in rural areas of Karnataka by the National Tuberculosis Institute, Bangalore, has been analysed in an attempt to identify significant categories of the population that may yield higher proportion of cases. In all, 170 cases diagnosed among 61,581 persons have been distributed by their role, i.e., head of family (HOF) or not, kinship, (relationship to the HOF) by age and sex.

It has been observed that a comparatively small size of HOF male population (16.9%) would contain 55.9% of the total cases prevalent in the entire X-rayed population. On the other hand, the broad category other than HOF-male, would have case content relatively much less in proportion to their population size. Implications of the finding for house-to-house Case-finding by Multi-purpose Health Workers (HWs) are discussed here. It is possible to obtain higher case yield from the group having a higher case content which is aged 20 years and above and constitutes about 30% of the total population by confining to symptom screening. On the other hand, since cases are mostly in the HOF-males, would make it difficult for HWs to contact them in their normal visiting hours during day, as most of HOF-males may not be at home. Determined efforts have to be made by HWs to contact them during their beat schedule.

The utility of repeated estimates of prevalence rates of infection in children as a tool for surveillance in tuberculosis is now well recognized. Two prevalence surveys at an interval of 5 years were conducted by National Tuberculosis Institute, Bangalore, with the main objective of studying changes in prevalence rate of infection among children in the age group of 0-9 years. A total population of 42,343 residing in 90 randomly selected villages of Doddaballapur taluk, Bangalore, were registered; of them, 12,535 were children in the age group of 0-9 years. Children were further classified into two sub groups 0-4 and 5-9 years, with or without BCG scars. The unvaccinated children in these two age groups formed the study population.

The population in the study area during the 2nd repeat survey was similar to that of first survey with regard to age, sex distribution, except that a growth rate of 1.1% per year was registered. The BCG scar rate, among children in the age group 0-4, 5-9 years, was 8% & 39% respectively at survey I. All the unvaccinated children below 10 years were given tuberculin test with 1 TU PPD RT 23 and reactions were read 72 to 96 hours after tuberculin testing. In the first survey, level of demarcation to classify the infected children was 10 mm and above, while in II survey it was 12 mm and above. It was observed that the prevalence rate of infection from I survey to II survey was not altered (2.58% & 2.46%) in the 0-4 years of age, while there was an increase in the rate from 8.93% to 12.3% in 5-9 years of age in the II survey. The increase in the infection rate could be attributed to the rising trend of infection, over reading by tuberculin-readers', skills of both tuberculin tester and reader, boosting of tuberculin reaction or scarless BCG vaccination. In conclusion, the study of changes in the prevalence rate of infection in the younger age group is simple, cheap, less time consuming. The data can be used for calculating annual risk of infection as well trend of transmission of infection.

Illness is mostly a subjective awareness of an individual, the relief of which may be sought within or outside medical or health facilities. Perception of illness vary from people to people depending upon cultural, ethnic and socio-economic differences. Perception of symptoms by persons suffering from tuberculosis is very high yet only half of them approach modern medical facility for alleviation of their suffering. A survey was carried out in rural area of Hoskote taluk, Bangalore district to determine perceived morbidity and accessible medical relief in 1433 households belonging to 18 villages; of them, 1393 (97%) were successfully interviewed. Selected households belonged to three types of villages i.e., those being within 3 kms of a i)PHC, ii)taluk headquarters hospital and non- Governmental health centre.

Of the 9286 individual belonging to 1393 households satisfactorily interviewed regarding health, 1201 (12.9%) were found to be ill at some point of time during the reference period of one month. No differences were observed in the perception of morbidity or in the health seeking behaviour in the three groups of villages. Persons with symptoms/disease accounted for 88.8% of the total sickness, 3.4% for injuries and 9.3% for disabilities, while action taking was 61.6%, 90% and 13.5% respectively. Age sex distribution showed no difference in illness occurrence. Sputum was collected from 147 chest symptomatics and seven were found to be sputum positive. Government health facilities were utilized by 37.6% of the sick persons, private doctors by 36.4%, nature medicine by 10.6% and home remedies by only 9.9%. In conclusion, the services at the government health facilities were acceptable and were utilized if accessible. Prompt and adequate relief for injuries and acute indispositions ensures confidence of the people and better utilization.

At present most of the districts in India have a TB clinic at the district headquarters, where TB patients are diagnosed and treated. Most of the clinics serve the town population and only a small proportion of the rural population are able to attend the clinics due to long distances. The wide distribution of patients in rural areas will necessitate the provision of extensive anti-tuberculosis services and they should be provided as near to the patients' home as possible. This cannot be achieved by creating large number of specialised services (TB clinics) in the district, as this will not only be beyond the resources but wasteful. As such, provision of anti-tuberculosis services in rural areas can be achieved by integration of the primary health centres and dispensaries. The problems of treatment in rural areas are envisaged as technical, organizational and personnel. Under the technical problems, the choice of anti-microbials is considered. The anti-microbials should be effective, cheap and acceptable to the patients. INH PAS, INH alone or INH Thiacetazone are considered suitable. Streptomycin containing drug regimens are difficult for the health services to deliver them to the patients in rural areas. Even with oral drugs INH + PAS or INH alone, drug regularity are 26.3% and 24.6%. The other technical limitation of treatment is the probability of increase in drug resistance due to the wide application of drug treatment which might be irregular. This has not been considered as enough justification for withholding treatment to the vast majority of patients, as its epidemiological and clinical significance in India are yet to be fully understood. The District TB Programme provides a firm organisational structure on the basis of which improvement can constantly be introduced for smooth functioning, constant supervision, proper orientation training and demonstration of the programme by the District TB Centre if necessary.

The organisational problems listed are: irregularity of drug intake and drug collection; their identification, default at drug collection, intake and remedial action, maintenance of records, check up while on treatment and follow up after completion of treatment. The paper suggests that regular collection could be taken as an index of regular drug intake. Defaulter actions could retrieve about 30% of the defaulters. Check up during treatment as well as follow up after treatment were found to be not acceptable to the patients due to a number of reasons. Training of staff to render services is also one of the biggest hurdles. The remedial measures are stressing tuberculosis as a community problem at the undergraduate and post graduate levels, training of the staff at every level of the programme and arrangement of seminars and group discussions with the administrators and medical personnel.

The broad relationship between the extent and pattern of sickness in a south Indian rural community, attendance at the Area Health Centre (AHC) and service rendered to the sick at the centre were studied by National Tuberculosis Institute (NTI), Bangalore. The objectives were to study (i) point prevalence of symptoms of all kinds and their pattern (ii) attendance at the AHC and the pattern of symptoms among them: and (iii) number of visits for each spell of sickness, by nature of symptom, laboratory tests offered, and referral to better equipped health institutions. A 30,000 population served by the Bettahalasur Primary Health Centre (PHC) which is 20 km. away from Bangalore city was chosen. The selection of villages was done by random sample so that about 1000 persons from each of 5 field health workers' area was available for symptoms questioning. The out patients at the PHC were questioned for symptoms by the PHC medical officer in a manner exactly similar to that for the community by the trained NTI para medical staff. The answers given by patients were recorded by NTI staff both at the centre and at the community. On revisits made for the same spell of sickness, the interval in days from the first visit, any laboratory tests done and reference to better equipped institutions were also recorded.

The point prevalence of sickness in the area was 9.5%; cough, pain and fever, in that order were the three cardinal symptoms that accounted for 68% of the total sickness in the community. Only 1.3% of the sick, at any point of time, had attended the AHC but the attendance by the sick persons residing in the village where the health centre is located was 9.2%. The composition of the out patients attendance was significantly different from that of the sick in the community in respect of age, sex and symptoms. Thus, women and the elderly persons who also constitute a major reservoir of tuberculosis, tended to disregard their symptoms while younger persons in the productive age group had availed the health centre facilities more freely. Among symptoms, cough was the most ignored. Of the total out patients, 71% had attended only once, 18% twice and 11% three times or more for any particular episode of sickness. Only 7 9% were offered laboratory examination and an insignificant number were referred to better equipped health institutions.

There is a wide spread prejudice among the staff of health centres that patients invariably prefer injection and it was felt by many health workers that streptomycin containing intermittent regimens would be more acceptable to rural patients. A study was carried out to find out the acceptability and applicability of an intermittent supervised drug regimen containing streptomycin 1 gm and INH 650 mgm once a week in a rural area as well as the regularity with which the rural folk took this treatment. Association between the observed regularity and factors like age, sex etc., was also analysed. 107 rural patients of tuberculosis, diagnosed at 5 taluk hospitals in Ananthapur district of Andhra Pradesh on the basis of sputum examination by direct smear and/or X-ray examination with the help of mobile X-rays, consented to treatment with intermittent regimen mentioned above. About half of them were new patients and the rest were old patients who were mostly regular on an earlier oral regimen. 94 of the above were available for analysis.

The regimen was found quite practicable in the sense that at no centre the study was interrupted or discontinued because of the inability of the health centre staff to give injection. If regularity is expressed as a proportion of patients who at any given time had taken the optimal amount of treatment (no. of injections), then 40 patients (42%) were found regular on the intermittent regimen, 36 patients were classified as lost and the remaining had 3 or less injections due and had not yet had the chance to become lost according to the definition adopted. Thus, the regularity of those accepting the regimen was quite low. There was very steep fall in regularity during the first 10 weeks of treatment, nearly a half of the total cases became irregular during the first 6 weeks. Beyond 4 months of treatment, patients who continued to attend centres regularly for treatment became negligible, thus pointing that injection was not a key variable in the treatment regularity of tuberculosis.

A study on acceptability of BCG vaccination, through specialised technicians in a population of 8350 residing in 8 villages of Channapatna taluk of Bangalore district, was carried out by National Tuberculosis Institute. Of the 1106 households satisfactorily interviewed, 956 (86.4%) had at least one child eligible for vaccination. For the purpose of analysis they were classified into three groups. Group I consisted of 312 (32.6%) households in which all children were vaccinated, Group II 270 (28.2%) where non-e of the children were vaccinated and Group III 374 (39.2%) households where only some of their children were vaccinated. Overall vaccination coverage was 52.7% with a range of 33.9% to 79.3%.

The reasons for refusing vaccination were studied. The caste, occupation, education etc., of the household did not have any influence on the refusals. When analysed according to the knowledge and opinion about vaccination it was observed that 55.9% of the children were not vaccinated because of the lack of knowledge in the group where no child was vaccinated. Even when 42% had favourable opinion about vaccination, 52% of the households did not vaccinate any of their children. The refusals were mainly due to (i) absence from the village on the day of vaccination, (ii) fear of prick. Among households where there was unfavourable opinion, all had refused due to fear. The reasons for accepting BCG vaccination were (i) the vaccination was done in the school and hence there was no option for the parents to accept or refuse, (ii) parents felt that the vaccination was good for children, (iii) parents knew that it would prevent TB.

Feasibility of introducing limited active case-finding in tuberculosis involving Multi-purpose Health Workers (HWs) to supplement the existing methodology of detecting the cases through chest symptomatics attending Peripheral Health Institutions (PHIs) on their own, was studied earlier with encouraging results. The present study was undertaken to understand the existing working system of HWs and within that the priority areas of input which may lead to better case yield.

The study revealed that the population available at any beat schedule of HWs was about 42% of the eligible population of age 20 years and above. Only 60-75% of the field days were utilized for routine multi-purpose duties. Of the total area, 25% to 40% remained uncovered. The effective tuberculosis work was done only on 5% of the beat schedule days and the work was not uniformly spread throughout the month. Even so, the contribution by HWs was twice the number of cases diagnosed at PHIs under study in one year. Had the HWs covered the entire area of their beat schedule, 80 against 26 cases would have been diagnosed. Moreover, there is possibility of detecting more cases among the elderly patients who normally do not attend their area health centres. However, the success depends upon meticulous supervision and regular flow of supplies.

A comprehensive baseline survey was undertaken in two contiguous districts of Salem and South Arcot of Tamil Nadu for strengthening the health and family welfare services with the assistance of the Danish International Development Agency (DANIDA). The main objectives of the study were to obtain data on the prevailing health status of population, the village organisations and leadership in health matters and important aspects of the health system of the area, such as Primary Health Centre (PHC), Medical Officer (MO) and para medical personnel identified as field health workers.

a) Medical Officers: A questionnaire was canvassed by post mainly in June/July 1982 after briefing the Medical Officers at their monthly meetings at Health Unit Districts. Out of 221 posts of Medical Officers (MOs) in 72 Primary Health Centres (PHCs), 68 were vacant. Of the 153 MOs in position, replies were received from 119 (78%), 69 in Salem and 50 in South Arcot. Among these MOs, 87 were men and 31 women, and 71% were in the age group 30-39 years. Proportions of married were 87% in men and 71% in women. Of the 119 MOs, 111 were qualified in allopathic system of medicine. Though 52% stated that they had training in rural health services, only 26% mentioned that they were trained at Health & Family Welfare Training Centres (HFTC). About 50% of MOs had total work experience in Health Department of 1-4 years and 25% of 5-8 years. Of the average service of 4.62 years in this department, 3.09 years were in the PHCs where they were working at the time of the survey. The overall ranking of functions of MOs was 1) curative (60.5%), 2) Preventive (41.2%), 3) Promotive (23.5%), 4) Supervision (35.3%) and (5) & (6) Public relations (23.5% and 41.2% respectively). Administration had the highest percentage for 2nd and 4th rank. MOs trained in rural health, however, had given more importance to working with block officials as compared to other MOs. Though nearly 75% MOs had stated that they plan a weekly schedule of work, while giving the detailed schedule, a maximum of 48 MOs had included outpatient clinic on any day of the week and the position with regard to important managerial functions and rural services was much worse. About one third did not conduct any mobile clinic during the month prior to the survey; 28% did not answer the question and the remaining 40% had conducted 2 or more clinics. Most of them have provided curative treatment and not promotive or preventive services. About 43% stated that there were no voluntary organisations working in their area and more than 80% of MOs stated that private medical practitioners did not take any help from them. About 50% said that neither the private practitioners nor voluntary organisations participated in the health activities i.e., immunisation, health camps and family planning, conducted in the villages. About 22% stated that villagers did not participate in the health activities. While 23% had no difficulty in working at PHCs, 30% mentioned lack of facilities at PHC, 18% each stated personal problems, heavy work load/lack of staff and more administrative work and 16% transport problem. About 30% mentioned that there were no problems, 44% mentioned staff vacancies, 24% lack of cooperation from staff and 14% staff changes. While 47% found no advantage in working in a PHC, 27% mentioned about provision of better services to the rural areas, 18% about better understanding of basic health problems and 8% wider experience including management. About one third only gave the relevant suggestions for improvement of the centres. The MOs at PHCs can play a crucial role in the delivery of health services in rural areas. They are the leaders of the health team at the grass root level with adequate technical knowledge and a very high degree of acceptability. The findings of the present study are therefore, very valuable and the shortfalls and deficiencies listed below have to be given adequate attention: i) All posts of MOs and staff to be filled. ii) Provision of facilities to staff at PHC. iii) MOs should give more attention to public health activities. iv) Adequate supervision of work of MOs and special training to them in rural health.

b) Primary Health Centre: In the rural areas, Primary Health Centre (PHC) is the nerve centre of the health services both institutional and community oriented. It was planned to obtain some basic data on the organisational structure, area of responsibility and functioning of PHCs and utilisation by the people of the services provided by PHCs. All the 72 PHCs in the project area were studied through a questionnaire cum interview schedule. Further, data and clarifications were obtained through interviews from the Medical Officer In charge of PHC and knowledgeable staff such as Health Inspector (General) and Block Extension Educator. The data were collected during June 1983 to January 1984. The area of coverage of 82% of PHCs was within 300 sq. kms., 194 sq.kms in Salem (District I) and 237 sq.kms in South Arcot (District II). Thus, PHCs in South Arcot generally covered more area and more villages and served larger populations. About half of the PHCs could not provide information on scheduled caste and scheduled tribe populations who are part of the target population under the project. Out of 1175 sub centres for which information was available, 72% were within 20 kms. of PHC. This was so for 84% of 548 sub centres in District I but only for 62% of 637 sub centres in District II. The average distance of sub centres from PHC was 12.3 kms. in District I, 18.4 kms (one and a half times) in District II and 15.7 kms at project level. Organisation: The average number of villages per sub centre was almost the same in both districts (3.3 and 3.4). A sub centre covered an average population of 4,800. All but two PHCs were in standard building and all were electrified. Nearly half of the PHCs were located outside the village after which it was named. No other medical facility was available within one kilometer reach in 40% of PHCs in District I and 70% in PHCs in District II. Vacant posts were more among Medical Officers (37.6%) and Medical Officers (indigenous) (36.4) and less among para medicals (16% among supervisors and 10% among workers). While about one third of the PHCs did not have separate laboratory, about half did not have separate injection/dressing room and Minor OT. While most of the PHCs had refrigerator and microscope, 77% of the former and 93% of the latter were in working order. Functions: The main training activities of PHCs were Dais Training & Orientation Training Camps for which the average number of courses per PHC during the year prior to the survey were 3.1 and 2.6 respectively. Health education activities were mainly confined to group meetings and distribution of publicity material, with average annual performance of 70.3 and 53.8 respectively. Average outpatient attendance per PHC during the previous year was about 36,500 of which 19,600 were new outpatients. On an average, 98 patients were admitted in beds in a PHC (120 in District I and 71 in District II). For all the MCH activities except distribution of iron and folic acid to women and giving polio vaccine to children, District II had fared much better than District I. While for the other two activities mentioned above District I fared better. There was no uniformity between PHCs and districts in the number of tablets of iron and folic acid given per woman. Tuberculosis : The average percentage of persons with symptoms of TB was 1.8 (2.1 in District I and 1.5 in District II) as compared to the expected rate of 2.6% based on a study by the NTI. Identification of symptomatics from new out patients is on the low side, particularly in District II. As against the expected positivity rate of 10% among sputum smears examined, the rate was 14.4% (8.1% in District I and 21.4% in District II). The reason for such differences need to be studied in depth. Leprosy : Since leprosy work is carried out by special teams, most of the PHCs are not aware of the work done in their areas. Malaria : The average rate of fever cases identified per 1000 population during the month prior to the survey were 8.1% and 15.7% respectively. The figures for blood smears made were almost the same. The average number of persons given anti malarial drugs (mostly chloroquine) per 1000 population were 8.0 in District I and 20.7 in District II. Chlorination : In District I where a PHC covered an average of 51 villages, 84 wells were chlorinated during the month prior to the survey. The corresponding figures for District II were 111 villages and 89 wells chlorinated per PHC. Registration of births & deaths : The birth rate on the basis of births recorded by PHCs was 13.3 per 1000 which is less than half of the birth rate for Tamil Nadu for 1983. The recorded death rate was 8.3 per 1000 as compared to an expected death rate of 11.5. Recording of births and deaths needs considerable improvement in almost all PHCs. Referral : Among 64 PHCs who gave information on referral of patients for tertiary care, 21 referred to one hospital, 34 to either of two hospitals and 9 to anyone of three hospitals. Records & Reports : Surprisingly, PHCs gave a wide range of answers about the records and reports they maintain. Though there is a general complaint that records and reports are too many, there were hardly any useful suggestions about which records and reports could be simplified and reduced. Targets : Another surprising finding is that there was no unanimity in the answers from PHCs about the units of period for achieving targets under national programmes. Supervision : With regard to supervision of non- medical staff at PHC there was no uniform pattern. Medical Officers carry out field visits mainly for either control of epidemics or to pay surprise checks. Collaboration : Most of the PHCs did not seek collaboration of other Government departments, voluntary organisations or community leaders. The limited collaboration sought was mainly for Family Welfare Programme. Only about 60% of PHCs felt that the community can participate in Immunization, 52% in Family Welfare and 15% in Epidemic Control. Most frequent illness : Conditions affecting digestive and excretory systems were mentioned as the most frequent illness in their area by 38 out of 68 PHCs, followed by conditions affecting respiratory system by 32 PHCs, pyrexia of unknown origin by 20 PHCs, and skin diseases by 14 PHCs. Health problems : When asked about the health problems in villages, replies from PHCs dealt with diseases (illness) problems only.

The main weakness of the PHCs was observed with regard to management, inter departmental collaboration and community involvement as reiterated below: At least 40% of PHCs did not have 1981 census figures for population. Further, about half of them did not have population figures for scheduled castes and scheduled tribes. Recording of births and deaths are far from complete. Further, there is considerable indifference towards maintenance of all records and reports. The Medical Officers In charge, do not supervise the other Medical Officers of PHCs. Their knowledge about functions of para medical staff was inadequate. Under these circumstances neither could the Medical Officer In charge ensure adequate and proper supervision by the para medical supervisors nor guide them in their work. Acute shortages of Vitamin "A" and general medicines were reported. So also for mass media equipments such as film projector and sound system. Collaboration with other departments and voluntary organisations was quite weak. Contacts with community leaders either to understand the health problems as conceived by them or to seek the co-operation of the community were also at a low ebb. IUD insertions which benefit the younger couples or those with small families were quite negligible and the stress was on sterilisation only which benefit mainly older couples or those with already large families. Health education activity of PHCs was at a very low ebb.

c) Field Health Worker : The field health workers who consists of Health Workers (HWs) and Health Supervisors (HSs) were identified as important para medical workers. They play the most crucial role as they have daily contact with the rural population in their homes. The main objectives were to obtain a profile of field workers, to ascertain the area of responsibility, health services rendered by them, community responsibilities and supervisory functions of the HSs. The information was collected through pretested interview schedule. Of the 326 HSs and 2349 HWs in position, 165 were interviewed. The majority of male HWs were of age 30-39 years, while female HWs were of age 20-29 years. All the HSs and all but one of the male HWs were married. Among female HWs, half were married and about 88% of female HSs were married. Vast majority of HWs and HSs had education upto secondary level. The pattern with respect to these profiles was similar in both the districts. Of the male HWs 65% and of the female 32% had training in multi purpose work. While 83% of male HSs and 45.5% of female HSs had multi purpose work training, supervisory training was received by only 1.8% of male HSs and 9.1% of female HSs. With regard to total experience in the health and family welfare department, male HWs had more experience than female HWs. The difference was even bigger in average years and experience between male and female HSs. On an average, 6 villages were allotted to male HW and 4 to female HS, a male HW had to cover an average of 2291 families as compared to 1014 for a female HW. On an average, HW had to travel 6.8 kms to cover the villages allotted. The male HWs approached the villages by cycle or walk while female HWs by walk and bus. Availability of trained dais in the villages was reported by 40.9% of HW(F)s as compared to 50% of HW(M)s. Similarly, according to them about half of the villages have community leaders. Contact of HWs with such bodies need improvement. To the question on number of patients attending SHC services, 80% did not give an answer. The average attendance by HW(F)s was 7. Services given by HWs in villages allotted were malaria, FP & HE. The services received lower priority were TB, environmental sanitation, school health and registration of births and deaths. While 76.3% of HW(F)s maintained that they have a weekly schedule, only 46% of HW(M)s have weekly schedule. On an average during a month HW(F)s worked for 22.4 hrs and HW(M)s for 23.0 hrs in the village. On an average, 12 households are covered per hour. About three fourths of HW(M)s stated that they carried paracetamol to the village, 19.2% sulpha guanidine and 15.4% chloroqine. Among HW(F)s, 76.3% carried anti anemic drugs, 68.4% multi vitamin tabs and 47.3% anti malaria drugs. No medicine was carried by 44.3% of HS(M)s, and 24.2% by HS(F)s. Only 54% of HW(M)s and 74% of HW(F)s mentioned that they provided family planning services in the villages. Supervision of FP work by HSs is also very poor. Few HWs and HSs carried nirodh, oral pills or FP register when they visited the villages. Complaints that the high target for FP hampered health activities appears to be a cover up only. About 45% to 69% of health workers and supervisors said that TB work was not applicable to them. Similarly 42% to 50% also mentioned that nothing to be done for diagnosis of leprosy. Regarding the aspect of their work which are supervised by their supervisors, many did not reply and the others gave a variety of isolated answers. There is urgent need to give training to medical officers and health supervisors on how to carry regular qualitative supervision. The HWs make frequent visits to PHCs, some of them going once a week. This may interfere with the actual work in sub centres.

d) Trained Birth Attendant : In spite of the request to the PHC staff and village leaders to ensure that the trained dais of the selected villages were present, only 24 out of the 80 Dais were present during the survey. They were interviewed. About 54% of them belonged to families in which women attended to births by tradition. About 63% were illiterate, 29% had a monthly income of Rs.100/ or more. Fifteen belonged to backward classes seven to SC one each to ST & Christianity. Two thirds were trained before project started. Over 90% had experience of 5 years or more. Only two thirds of the trained dais have received the kits and less than half had received practical training in conducting deliveries. Different aspects of ante natal care were mentioned as follows: 82% periodical check up, 59% tetanus toxoid and 46% iron and folic acid. The number of deliveries conducted by trained dais was the same as before and after training. Majority of dais do not report births to health personnel. About 75% of the trained dais had referred at least one woman for delivery to ANM or hospital during the previous month. Eleven of the 24 dais, had no difficulties in carrying out their work while an equal number mentioned inadequate regular income. Trained dais were mostly aware of ANMS but not of Basic Health Worker, Malaria Worker or Health Inspector. Neither educational status nor experience had any influence on the functioning and working pattern of the trained dais. There were equal number of untrained dais, it would be worthwhile to train them also. Dai is important liaison between PHC and village for child births, post-natal care, family planning and registration of birth. Some future thought had to be given about their regular income, providing of kits, the replenishment and supervision during frequent visits by Health Workers and Health Supervisors. This will go a long way in ensuring co-operation from trained dais and in boosting up the morale of these village level workers of low socio economic standing which will make them useful participants in grass root level health activity.

e) Village Appraisal : Appraisal of the villages with their multi sectoral needs and activities would provide a third dimension to the survey. An appraisal of sample villages was conducted along with the household survey during June-November 1983. The method of group discussion was adopted to collect the data for village appraisal. Group discussions were held separately for SC & ST so that they could express their views freely (Adi Dravida colonies). This report is based on the information collected through group discussions in 71 main villages and 35 Adi Dravida(AD) colonies. About 45% AD colonies did not generally avail of services at PHC and one fifth did not avail of any service from HWs. Most of the groups felt that allopathic doctors were accessible to them followed by homeopaths. Contrary to expectations accessibility to practitioners of Indian system was poor. ANMs were more accessible to main villages than AD colonies. More than three fourth of main villages and AD colonies stated accessibility of dais. Most of the general facilities were accessible to a large extent except community centre and library. One of the main source of water was pucca well for three fourths of people. About 40% mentioned kutcha open well or river/canel. Latrines were few. Open field was generally used. Both manure pits and scattering was used for disposal of refuse to a large extent. Nearly all let out sullage to open places. About 50% of the villages mentioned that there was no developmental activity during last 12 month period prior to this appraisal. The activities mentioned more frequently were mid day meal scheme, water supply, school building, road construction and health centre. Most of the villages were not aware of who had taken the initiative for these activities. About 10% stated that there were no TB & leprosy cases among them while most of them mentioned DTC, general hospital or PHC as source of treatment of TB. Major problem of the villages were lack of water, transport and communication. Others mentioned were facilities for treatment and for education. Participation of women and younger generation in the group discussion was more in AD colonies than in main villages. According to villagers fever was the most common illness, followed by gastro intestinal disorders, diseases of respiratory system and eye complaints. Main causes of ill health were lack of sanitation and protected water supply. The perceptions by villagers pointed out the need for not only improving the availability and accessibility of service facilities but also for educating the villagers about how these could be made use of. The bigger and most important gaps would appear to be the provision and/or utilisation of preventive and promotive services, in availing of treatment facilities at PHCs and in reporting of births and deaths. Community involvement in all development activities would lead to informed participation in all developmental activities.