BACKGROUND Immunisations are one of the most cost-effective public health interventions available and South Africa (SA) has implemented a comprehensive immunisation schedule. However, there is disagreement about the level of immunisation coverage in the country and few studies document the immunisation coverage in rural areas. OBJECTIVE To examine the successful and timely delivery of immunisations to children during the first 2 years of life in a deeply rural part of the Eastern Cape Province ot SA. METHODS From January to April 2013, a cohort of sequential births (N=470) in the area surrounding Zithulele Hospital in the OR Tambo District of the Eastern Cape was recruited and followed up at home at 3, 6, 9,12 and 24 months post birth, up to May 2015. Immunisation coverage was determined using Road-to-Health cards. RESULTS The percentages of children with all immunisations up to date at the time of interview were: 48.6% at 3 months, 73.3% at 6 months, 83.9% at 9 months, 73.3% at 12 months and 73.2% at 24 months. Incomplete immunisations were attributed to stock-outs (56%), lack of awareness of the immunisation schedule or of missed immunisations by the mother (16%) and lack of clinic attendance by the mother (19%). Of the mothers who had visited the clinic for baby immunisations, 49.8% had to make multiple visits because of stock-outs. Measles coverage (of at least one dose) was 85.2% at 1 year and 96.3% by 2 years, but 20.6% of babies had not received a second measles dose (due at 18 months) by 2 years. Immunisations were often given late, particularly the 14-week immunisations. CONCLUSIONS Immunisation rates in the rural Eastern Cape are well below government targets and indicate inadequate provision of basic primary care. Stock-outs of basic childhood immunisations are common and are, according to mothers, the main reason for their childrens immunisations not being up to date. There is still much work to be done to ensure that the basics of disease prevention are being delivered at rural clinics in the Eastern Cape, despite attempts to re-engineer primary healthcare in SA.

Background: More than 50% of Africa's population lives in rural areas, which have few professional health workers. South Africa has adopted task shifting health care to Community Health Workers (CHWs) to achieve the Sustainable Development Goals, but little is known about CHWs' efficacy in rural areas. Methods: In this longitudinal prospective cohort study, almost all mothers giving birth (N = 470) in the Zithulele Hospital catchment area of the OR Tambo District were recruited and repeatedly assessed for 2 years after birth with 84.7-96% follow-up rates. During the cohort assessment we found that some mothers had received standard antenatal and HIV care (SC) (n = 313 mothers), while others had received SC, supplemented with home-visiting by CHWs before and after birth (HV) (n = 157 mothers, 37 CHWs). These visits were unrelated to the cohort study. Multiple linear and logistic regressions evaluated maternal comorbidities, maternal caretaking, and child development outcomes over time. Results: Compared to mothers receiving SC, mothers who also received home visits by CHWs were more likely to attend the recommended four antenatal care visits, to exclusively breastfeed at 3 months, and were less likely to consult traditional healers at 3 months. Mothers in both groups were equally likely to secure the child grant, and infant growth and achievement of developmental milestones were similar over the first 2 years of life. Conclusion: CHW home visits resulted in better maternal caretaking, but did not have direct benefits for infants in the domains assessed. The South African Government is planning broad implementation of CHW programmes, and this study examines a comprehensive, home-visiting model in a rural region.

Aims: To examine child outcomes over time among mothers with perinatally depressed mood in rural South Africa (SA). Methods: A representative sample of consecutive births (470/493) in the OR Tambo District of the Eastern Cape of South Africa (SA) were recruited and were reassessed at five points over the course of the next two years: 85% were reassessed at 3 months, 92% at 6 months, 88% at 9 months, 91% at 12 months, and 88% at 2 years post-birth. Over time, the children of mothers with perinatally depressed mood (16%) were compared to children of mothers without depressed mood using multiple linear and logit regressions.

Access to healthcare in developing countries remains a challenge. As a result, taskshifting to community health workers (CHWs) is increasingly used to mitigate healthcare worker shortages. Although there is solid evidence of CHW program effectiveness, less is known about CHWs' experiences of becoming and then working daily as CHWs-information that should play an important role in the design of CHW programs. We examined the experiences of a group of CHWs working in a government-run CHW program in South Africa's rural Eastern Cape Province.Semistructured qualitative interviews (N = 9) and focus groups (N = 2) focusing on motivations for becoming a CHW and experiences of working as CHWs were conducted and thematically analyzed. Three themes were identified: (1) becoming a CHW, (2) facing challenges in the field, and (3) gaining community acceptance through respect and legitimacy. In this study, CHWs were motivated by altruism and a desire to help their community. They faced a range of challenges such as limited training, lack of supervision, equipment shortages, logistical issues, and clinics with limited services. Respect and legitimacy through community acceptance and trust is crucial for effective CHW work. CHWs in this study described how confidentiality and their own persistence facilitated the process of gaining respect and legitimacy.CHWs have a unique knowledge of contexts and requirements for successful programs and greater efforts are needed to include their perspectives to improve and develop programs. Recognition is needed to acknowledge the significant personal input required by CHWs for programs to be successful.

Immunisation coverage of children is a cornerstone of primary healthcare (PHC) and an important gauge of the quality of the health service in a country, [1] but is also a good indicator of how far a country is from preventable disease outbreaks, such as the measles outbreak that occurred in South Africa (SA) in 2010. [2] SA's immunisation schedule has been significantly expanded since 1994, with the recent addition of the pneumococcal (PCV) and rotavirus (RV) vaccines in 2009, [3] and is the most comprehensive in Africa. [4] As part of the 2010 'Re-engineering of Primary Health Care' policy, the South African National Department of Health (NDoH) has emphasised the importance of doing the basics of PHC right. [5] However, there has been disagreement about how well the schedule has been implemented on the ground and the NDoH has disputed low WHO/UNICEF immunisation coverage figures. [3,6] After the 2011 census provided revised estimates of the number of children under the age of 1 year, the NDoH immunisation indicators were adjusted downwards, but were still significantly higher that WHO/UNICEF estimates. [4,7] The quality of NDoH immunisation data gathered through the District Health Information System (DHIS) is poor [6] and apart from one study, [8] there are limited data on immunisation coverage in rural areas of SA and, to the best of our knowledge, nothing about coverage in rural Eastern Cape. In this study we assessed immunisation coverage of the South African Expanded Programme of Immunisations (EPI-SA) during the first 2 years of life and the timeliness of immunisations in the first year of life. The study formed part of the Zithulele Births Follow up Study (ZiBFUS), a prospective, longitudinal cohort study, initiated in January 2013. Methods Setting Zithulele Hospital is a 146-bed district hospital, serving a catchment area with a population of approximately 130 000 [9] and fourteen clinics, and is situated in the King Sabata Dalindyebo (KSD) sub-district of the OR Tambo District in the Eastern Cape, a National Health Insurance This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.