The household, and people in the household
1777 persons, 898 adults and 879 children were recorded in 177 households visited (table ). 51 persons (2,9%) were referred and received a medical journal booklet at the end of the home visit, 13 adults (1,4%) and 38 (4,3%) children. 27 were males, 24 females. The reason for referral was noted in the booklet, to be presented at the hospital the next day. From two to seven persons were referred from each of the 11 central and suburban housing areas.
Number and characteristics of persons in the households
There were on average 10 persons in each household, five adults and five children. Almost half of the women 16–50 years of age had no schooling. Two per cent of women and nine per cent of men were daily smokers. A majority of the households (table ) had tap water. Mosquito nets and water closets were very uncommon. Median number of sleeping rooms in one household was 3, and median for the maximum number of persons sleeping in one room was 4. Most households appeared clean and well kept, but stagnant water was found in or adjacent to about one third of the households.
Number of children in a household was inversely correlated to schooling level for women (P = 0.032) and correlated positively with the maximum number of persons sleeping in one bedroom (P < 0.001, Pearson). The more children, the higher poverty index (P = 0.003, Kendall's tau). Relatively more children than adults were living in poor households (P = 0.019). More young children than older children were coughing (P < 0.001). Fifteen of 34 coughing children lived in a household with at least one smoker. Logistic regression analysis showed that coughing children were about three and a half times more likely than non-coughing children to live in a household with at least one smoker, and that they generally lived in more poor households (Table ). Twelve of 16 children with weight loss were referred from households with a high poverty score of 2 or 3, but this tendency was not significant in the adjusted model. Mainly the younger children had weight loss (P = 0.036 adjusted for poverty and passive smoking), but weight loss was not recorded before the age of one year.
Children who cough in relation to age, passive smoking and a poverty index. Logistic regression. CI=Confidence interval.
Sex and housing quarter were included in the first regression models, but showed no relationship to coughing children or to children with weight loss. There was no correlation between poverty score and smoking. Five housing quarters had an even distribution of the poverty score, while three housing quarters tended to have higher and three to have lower scores. The three housing areas with a majority of high poverty scores were relatively new residence areas with many newcomers from villages in the region. These three areas had relatively few smokers.
Four of the 51 patients did not show up; two sisters 6 and 1 year olds with coughing and fever, a 35 year old man and a 70 year old woman with coughing and weight loss.
The most frequent clinical signs on general examination in the hospital were reduced general condition and pathologic lung sounds. Other findings included abdominal signs, oedema, adenopathy, skin ulcers, neurological and orthopaedic pathology. Nine children had only minor findings.
Thick drop examination was performed in 41 cases and was positive in seven. Sputum examination was performed for ten adults and was positive in three. Tuberculin tests were done for three referred children and for several non-vaccinated children in families with sick adults. All were negative, and BCG vaccination was then offered. HIV serology was taken for seven patients where AIDS was clinically suspected. The test was positive for three adults and one motherless, ill-appearing one-year old boy. Haemoglobin was measured in 40 patients and showed anaemic values in four children and four adults. High sedimentation rates and neutrophilia in blood counts gave diagnostic information in a few cases. Twelve x-rays of chest were performed, pathologic findings were made in two children and eight adults. In nine of these cases pulmonary shadows were massive, uni- or bilaterally.
Thirty-five patients had serious or potentially serious disease (table 4; see Additional file 1
). Seven were hospitalised, including the three adults with tuberculosis. Malnutrition was diagnosed in nine children, eight of them 1–3 years old. Twelve of the 18 children younger than five years of age had weight measurements which deviated from "the road to health", i.e. their weight was below the 3 percentile for girls on the WHO growth chart [2
]. Seven of them had upper arm circumference 13 cm or less.
A six year old boy with a protruding tumour in his abdomen died after four weeks of cytostatic treatment for assumed lymphoma. Another six year old boy had advanced osteomyelitis in tibia, with several open wounds to the bone, the biggest measuring 7 × 4 cm (fig ). Bacterial culture showed Proteus, resistant to most relevant drugs. A third generation cephalosporine was given intravenously and surgical débridement was performed. After about a year the wound has healed, and the boy limps around with a crutch.
Osteomyelitis in a six year-old boy
Some sick people were not referred by the visiting team. Two adult men were on Tb-treatment, and two adults with a chronic cough had recently had a negative hospital examination for Tb. One man was depressed after his wife died in a car accident four months previously, the team had a long talk with him. Scabies medication was prescribed on the spot, and in one case penicillin was prescribed for a wound in the foot.
Two reported but non-referred patients should have been referred; a ten year old boy with inguinal/scrotal hernia since infancy, and a girl 9 years old with a history of 1–2 epileptic fits per year and slight affection of movements of right arm, mentally sane.
Total cost for diagnosis and treatment was noted for 45 of the 51 patients and was approximately 1300 USD. For the seven hospitalised patients, individual expenses varied from 30 to 175 USD, with an average of about 110 USD. Cost range for outpatients was 5 to 25 USD, on average about 15 USD.