• 농촌의학ㆍ지역보건
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• 제19권2호
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• pp.141-158
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• 1994

정부는 보건진료원으로 하여금 지역주민들에게 보다 더 의욕적으로 양질의 보건의료서비스를 제공하도록 하기 위하여 1992년 4월 1일부터 보건진료원을 별정직 공무원으로 정규직화 하였다. 본 연구는 보건진료원의 정규직화가 보건진료원의 업무활동과 보건진료소의 관리운영체계에 미친 영향을 분석하기 위해 경상남도와 경상북도의 보건진료소 중 집락추출법과 단순확률추출법으로 50개소를 뽑아 보건진료원을 대상으로 직접 면담조사하고 제반기록 및 보고서에서 필요한 자료를 발췌하였다. 조사기간은 1992년 1월 1일에서 3월 31일까지(정규직화 이전)와 1993년 1월 1일에서 3월 31일까지(정규직화 이후)였다. 보건진료원들의 96%가 정규직화를 원했는데 그 이유는 신분보장과 보수가 좋아지리라는 것이었다. 정규직화 후 보건진료원직을 자랑스럽게 생각한다는 사람이 24%에서 46%로 증가하였다. 신분보장에 대해서는 항상 불안하다는 사람이 30%에서 10%로 감소하였다. 정규직화 후 월평균 급여액은 802,600원에서 1,076,000원으로 34% 증가했으며 90%가 만족한다고 했다. 업무 내용별 자율성 인지정도는 업무계획, 업무수행, 진료소관리(재정)운영, 업무평가 영역에 대한 자율성 인지도가 정규직화 후에 증가되었다. 보건진료원의 활동내용 중 지역사회 자원파악, 지도작성상태, 지역사회조직 활용정도, 인구구조 파악정도와 가정건강기록부 작성은 정규직화 후에 특별한 변화는 없었다. 또한 집단보건교육, 개인보건교육, 학교보건교육의 실시도 정규직화 후에 변화가 없었다. 그러나 가정방문 실시현황은 1인당 월평균 13.6%회에서 정규직화 후에는 27.5%회로 늘었다. 모성보건 및 가족계획 사업 그리고 예방접종도 정규직화 후에 타기관에 의뢰하는 것이 더 늘었다. 통상질병관리 가운데 성인병관리는 3개월 동안 1개 진료소당 평균 고혈압환자는 12.7%명에서 11.6명으로, 암환자는 1.5명에서 1.2명으로, 당뇨병환자가 4.3명에서 3.4명으로 줄었다. 각종 기록부 비치상황은 장비대장, 약품관리 대장, 환자진료기록부는 100% 비치되었으나 기타 기록부는 그렇지 않았고 정규직화 후에도 변화는 없었다. 보건진료소가 보건소로부터 지원을 받는 내용은 약품 14.0%에서 30%로, 소모품 22.0%에서 52.0%로, 건물유지 및 보수가 54.0%에서 68% 로, 보건교육 자료가 34.0%에서 44.0%로 증가하였고, 장비는 58.0%에서 54.0%로 감소했다. 보건진료소의 월평균 수입은 진료수입이 약 22,000원 증가했고, 국비 또는 지방비 보조금이 4,800원에서 38,508%원으로 증가했으나 회비 및 기부금은 줄어 총수입은 약 50,000원 증가했다. 지출총액은 큰 변동이 없었다. 보건소로부터 3개월 동안 받은 지도감독 중 지시공문을 받은 진료소가 20%에서 38%로 늘었고, 방문지도는 79%에서 62%, 회의소집은 88%에서 74%로 감소하였다. 전화지도는 보건진료소당 평균 1.8회에서 2.1회로 늘었다(p<0.01). 면보건요원과의 협력관계가 있다고 한 보건진료원은 42%에서 36%로 감소하였다. 보건소장과의 관계가 좋다는 보건진료원이 46%에서 24%로 감소하였고, 보건행정계장과 관계가 좋다는 사림이 56%에서 36%로 감소하였다(p<0.05). 보건진료소 운영협의회 회장과의 관계가 좋다는 사람은 62%에서 38%로 감소되었고 보건진료소 운영협의회가 보건진료소에 별로 도움이 안된다와 전혀 도움이 되지 않는다는 사람이 정규직화 전과 후에 각각 92.0%, 82.0%였다. 운영협의회가 필요 없다는 사람은 정규직화 전에 4%에서 16%로 증가되었다(p<0.05). 보건진료원제도 발전을 위해 제안된 사항은 보건교육중심의 활동, 보건진료소운영의 자율성 보장 보건소에 경험이 풍부한 보건진료원을 두어 지도감독하게 할 것과 사용하는 약품의 종류를 늘려 줄 것 등이었다. 이상의 결과로 보하 정규직화 후 보건진료원의 역할, 기능 등의 업무활동의 변화는 거의 없었으나 신분보장과 봉급에 대한 만족도는 향상이 되었고 또한 자율성도 증가하였다. 보건소의 지원은 약간 늘었으며, 지도감독체제에서 지시 공문의 증가로 사무보고 업무가 많아지고, 근무 확인을 위한 전화감독은 늘었으나 업무치진을 위한 행정직 지도 또한 기술적 지도는 거의 없었다.

• 대한수의학회지
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• 제35권2호
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• pp.337-345
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• 1995

면역억제가 닭 콕시듐중 E tenella의 병원성과 면역원성에 미치는 영향을 조사하기 위하여 일반 육용계 아바에이카 초생추에 1일령, 2일령과 7일령에 수당 40mg의 testosterone propionate(TES) 또는 0.1ml의 dexamethasone(DEX)을 근육내 접종한 후, 14일령에 E tenella의 오오시스트 100개로 면역시킨 2주 후, 역시 E tenella의 오오시스트 100,000개로 공격접종하여 다음과 같은 성적을 얻었다. E tenella에 대한 병원성과 면역원성을 관찰하기에 앞서 2주령에 Newcastle disease(ND) oil-emulsion vaccine으로 예방접종하고 ND 바이러스에 대한 혈구응집억제반응 항체가를 조사한 결과 testosterone propionate 처리군이 dexamethasone 처리군과 대조군에 비하여 높게 나타났다 약물투여 초기 2주간의 증체량은 대조군이 264.2g인데 비하여 TES접종군은 171.9g이고 DEX접종군은 238.1g이었다 사료요구율은 대조군이 1.23인데 비하여, TES접종군은 1.63이고 DEX접종군은 1.32 이었다. E tenella 면역접종 2주후 증체량은 무투약 대조군이 488.2g인데 비하여, 무투약 면역접종군은 483.9g이고 TES주사 대조군은 252.5g이고 TES주사후 면역접종군은 196.0g이며, DEX주사 대조군은 503.3g이고 DEX주사후 면역접종군은 498.9g 이었다. 사료요구율은 무투약 대조군이 2.09인데 비하여 무투약 면역접종군은 2.40이고 TES접종대조군은 2.59이고 TES주사후 면역접종군은 3.85이며, DEX주사 대조군은 2.19이고 DEX주사후 면역접종군은 2.38이었다. E tenella 공격접종 1주후 증체량은 무투약 대조군이 393.4g인데 비하여 무투약 면역접종군은 380.6g이고 무투약 공격접종 대조군이 318.4g인데 비하여, 무투약 면역후 공격접종군은 288.6g이고, TES주사 대조군은 312.6g이고 TES주사후 면역접종군은 254.0g이며, TES주사후 공격접종군은 232.5g이고 TES주사 및 면역후 공격접종군은 197.7g이며, DEX주사 대조군은 445.0g이고 DEX주사후 면역접종군은 417.3g이었다. DEX주사후 공격접종군은 293.2g이고 DEX주사 및 면역후 공격접종군은 293.3g 이었다. 사료요구율은 무투약 대조군이 2.15인데 비하여 무투약 면역접종군은 2.41이고 무투약 공격접종 대조군이 2.90인데 비하여 무투약 면역후 공격접종군은 2.93이고, TES주사 대조군은 2.69이고 TES주사후 면역접종군은 2.86이며, TES주사후 공격접종군은 3.63이고 TES주사 및 면역후 공격접종군은 3.46이며, DEX주사 대조군은 2.25이고 DEX주사후 면역접종군은 2.39이었고 DEX주사후 공격접종군은 2.89이고 DEX주사 및 면역후 공격접종군은 2.87 이었다. E tenella 공격접종후 2주간의 증체량은 무투약 대조군이 789.1g인데 비하여 무투약 면역접종군은 722.0g이고 무투약 공격접종 대조군이 659.9g인데 비하여 무투약 면역후 공격접종군은 468.3g이고, TES주사 대조군은 652.7g이고 TES주사후 면역접종군은 545.2g이며, TES주사후 공격접종군은 399.5g이고 TES주사 및 면역후 공격접종군은 360.4g 이었다. DEX주사 대조군은 759.4g이고 DEX주사후 면역접종군은 745.1g 이었으며, DEX주사후 공격접종군은 664.1g이고 DEX주사 및 면역후 공격접종군은 577.1g 이었다. 사료요구율은 무투약 대조군이 2.27인데 비하여 무투약 면역접종군은 2.48이고 무투약 공격접종 대조군이 2.74인데 비하여 무투약 면역후 공격접종군은 3.05이고, TES주사 대조군은 2.70이고 TES주사후 면역접종군은 2.80이며, TES주사후 공격접종군은 3.46이고 TES주사 및 면역후 공격접종군은 3.43이며, DEX주사 대조군은 2.36이고 DEX주사후 면역접종군은 2.40이었고 DEX주사후 공격접종군은 2.72이고 DEX주사 및 면역후 공격접종군은 2.81 이었다. E tenella 면역접종 1주후 각 시험군마다 맹장 병변도는 관찰할 수 없었다. E tenella 공격접종 1주후 각 시험군마다 맹장 병변도는 무투약 공격접종 대조군이 2.8인데 비하여 무투약 면역후 공격접종군은 2.4이고, TES주사후 공격접종군은 4.0이고 TES주사 및 면역후 공격접종군은 2.4이며, DEX주사후 공격접종군은 2.8이고 DEX주사 및 면역후 공격접종군은 2.4이었다. E tenella 공격접종 후 각 시험군마다 생잔율은 TES주사 후 공격접종군은 61.5%이고 TES주사 및 면역후 공격접종군은 83.3%이며, 나머지 모든 시험군에서는 맹장콕시듐에 의한 폐사는 없었다. F낭과 흉선의 크기는 TES접종군에서 다른 시험군에 비하여 매우 위축되었으며, 기능적인 변화도 보였다. 그러므로 testosterone propionate는 닭에 있어서 성장에 미치는 영향이 클 뿐만 아니라, E tenella에 대한 저항성을 약화시키는 데에도 크게 영향을 주는 것으로 나타났다.

• Journal of Preventive Medicine and Public Health
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• 제20권1호
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• pp.165-203
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• 1987

This project was a service-cum-research effort with a quasi-experimental study design to examine the health benefits of an integrated Family Planning (FP)/Maternal & Child health (MCH) Service approach that provides crucial factors missing in the present on-going programs. The specific objectives were: 1) To test the effectiveness of trained nurse/midwives (MW) assigned as change agents in the Health Sub-Center (HSC) to bring about the changes in the eight FP/MCH indicators, namely; (i)FP/MCH contacts between field workers and their clients (ii) the use of effective FP methods, (iii) the inter-birth interval and/or open interval, (iv) prenatal care by medically qualified personnel, (v) medically supervised deliveries, (vi) the rate of induced abortion, (vii) maternal and infant morbidity, and (viii) preinatal & infant mortality. 2) To measure the integrative linkage (contacts) between MW & HSC workers and between HSC and clients. 3) To examine the organizational or administrative factors influencing integrative linkage between health workers. Study design; The above objectives called for quasi-experimental design setting up a study and control area with and without a midwife. An active intervention program (FP/MCH minimum 'package' program) was conducted for a 2 year period from June 1982-July 1984 in Seosan County and 'before and after' surveys were conducted to measure the change. Service input; This study was undertaken by the Soonchunhyang University in collaboration with WHO. After a baseline survery in 1981, trained nurses/midwives were introduced into two health sub-centers in a rural setting (Seosan county) for a 2 year period from 1982 to 1984. A major service input was the establishment of midwifery services in the existing health delivery system with emphasis on nurse/midwife's role as the link between health workers (nurse aids) and village health workers, and the referral of risk patients to the private physician (OBGY specialist). An evaluation survey was made in August 1984 to assess the effectiveness of this alternative integrated approach in the study areas in comparison with the control area which had normal government services. Method of evaluation; a. In this study, the primary objective was first to examine to what extent the FP/MCH package program brought about changes in the pre-determined eight indicators (outcome and impact measures) and the following relationship was first analyzed; b. Nevertheless, this project did not automatically accept the assumption that if two or more activities were integrated, the results would automatically be better than a non-integrated or categorical program. There is a need to assess the 'integration process' itself within the package program. The process of integration was measured in terms of interactive linkages, or the quantity & quality of contacts between workers & clients and among workers. Intergrative linkages were hypothesized to be influenced by organizational factors at the HSC clinic level including HSC goals, sltrurture, authority, leadership style, resources, and personal characteristics of HSC staff. The extent or degree of integration, as measured by the intensity of integrative linkages, was in turn presumed to influence programme performance. Thus as indicated diagrammatically below, organizational factors constituted the independent variables, integration as the intervening variable and programme performance with respect to family planning and health services as the dependent variable: Concerning organizational factors, however, due to the limited number of HSCs (2 in the study area and 3 in the control area), they were studied by participatory observation of an anthropologist who was independent of the project. In this observation, we examined whether the assumed integration process actually occurred or not. If not, what were the constraints in producing an effective integration process. Summary of Findings; A) Program effects and impact 1. Effects on FP use: During this 2 year action period, FP acceptance increased from 58% in 1981 to 78% in 1984 in both the study and control areas. This increase in both areas was mainly due to the new family planning campaign driven by the Government for the same study period. Therefore, there was no increment of FP acceptance rate due to additional input of MW to the on-going FP program. But in the study area, quality aspects of FP were somewhat improved, having a better continuation rate of IUDs & pills and more use of effective Contraceptive methods in comparison with the control area. 2. Effects of use of MCH services: Between the study and control areas, however, there was a significant difference in maternal and child health care. For example, the coverage of prenatal care was increased from 53% for 1981 birth cohort to 75% for 1984 birth cohort in the study area. In the control area, the same increased from 41% (1981) to 65% (1984). It is noteworthy that almost two thirds of the recent birth cohort received prenatal care even in the control area, indicating that there is a growing demand of MCH care as the size of family norm becomes smaller 3. There has been a substantive increase in delivery care by medical professions in the study area, with an annual increase rate of 10% due to midwives input in the study areas. The project had about two times greater effect on postnatal care (68% vs. 33%) at delivery care(45.2% vs. 26.1%). 4. The study area had better reproductive efficiency (wanted pregancies with FP practice & healthy live births survived by one year old) than the control area, especially among women under 30 (14.1% vs. 9.6%). The proportion of women who preferred the 1st trimester for their first prenatal care rose significantly in the study area as compared to the control area (24% vs 13%). B) Effects on Interactive Linkage 1. This project made a contribution in making several useful steps in the direction of service integration, namely; i) The health workers have become familiar with procedures on how to work together with each other (especially with a midwife) in carrying out their work in FP/MCH and, ii) The health workers have gotten a feeling of the usefulness of family health records (statistical integration) in identifying targets in their own work and their usefulness in caring for family health. 2. On the other hand, because of a lack of required organizational factors, complete linkage was not obtained as the project intended. i) In regards to the government health worker's activities in terms of home visiting there was not much difference between the study & control areas though the MW did more home visiting than Government health workers. ii) In assessing the service performance of MW & health workers, the midwives balanced their workload between 40% FP, 40% MCH & 20% other activities (mainly immunization). However, $85{\sim}90%$ of the services provided by the health workers were other than FP/MCH, mainly for immunizations such as the encephalitis campaign. In the control area, a similar pattern was observed. Over 75% of their service was other than FP/MCH. Therefore, the pattern shows the health workers are a long way from becoming multipurpose workers even though the government is pushing in this direction. 3. Villagers were much more likely to visit the health sub-center clinic in the study area than in the control area (58% vs.31%) and for more combined care (45% vs.23%). C) Organization factors (admistrative integrative issues) 1. When MW (new workers with higher qualification) were introduced to HSC, it was noted that there were conflicts between the existing HSC workers (Nurse aids with less qualification than MW) and the MW for the beginning period of the project. The cause of the conflict was studied by an anthropologist and it was pointed out that these functional integration problems stemmed from the structural inadequacies of the health subcenter organization as indicated below; i) There is still no general consensus about the objectives and goals of the project between the project staff and the existing health workers. ii) There is no formal linkage between the responsibility of each member's job in the health sub-center. iii) There is still little chance for midwives to play a catalytic role or to establish communicative networks between workers in order to link various knowledge and skills to provide better FP/MCH services in the health sub-center. 2. Based on the above findings the project recommended to the County Chief (who has power to control the administrative staff and the technical staff in his county) the following ; i) In order to solve the conflicts between the individual roles and functions in performing health care activities, there must be goals agreed upon by both. ii) The health sub·center must function as an autonomous organization to undertake the integration health project. In order to do that, it is necessary to support administrative considerations, and to establish a communication system for supervision and to control of the health sub-centers. iii) The administrative organization, tentatively, must be organized to bind the health worker's midwive's and director's jobs by an organic relationship in order to achieve the integrative system under the leadership of health sub-center director. After submitting this observation report, there has been better understanding from frequent meetings & communication between HW/MW in FP/MCH work as the program developed. Lessons learned from the Seosan Project (on issues of FP/MCH integration in Korea); 1) A majority or about 80% of the couples are now practicing FP. As indicated by the study, there is a growing demand from clients for the health system to provide more MCH services than FP in order to maintain the achieved small size of family through FP practice. It is fortunate to see that the government is now formulating a MCH policy for the year 2,000 and revising MCH laws and regulations to emphasize more MCH care for achieving a small size family through family planning practice. 2) Goal consensus in FP/MCH shouBd be made among the health workers It administrators, especially to emphasize the need of care of 'wanted' child. But there is a long way to go to realize the 'real' integration of FP into MCH in Korea, unless there is a structural integration FP/MCH because a categorical FP is still first priority to reduce the rate of population growth for economic reasons but not yet for health/welfare reasons in practice. 3) There should be more financial allocation: (i) a midwife should be made available to help to promote the MCH program and coordinate services, (in) there should be a health sub·center director who can provide leadership training for managing the integrated program. There is a need for 'organizational support', if the decision of integration is made to obtain benefit from both FP & MCH. In other words, costs should be paid equally to both FP/MCH. The integration slogan itself, without the commitment of paying such costs, is powerless to advocate it. 4) Need of management training for middle level health personnel is more acute as the Government has already constructed 90 MCH centers attached to the County Health Center but without adequate manpower, facilities, and guidelines for integrating the work of both FP and MCH. 5) The local government still considers these MCH centers only as delivery centers to take care only of those visiting maternity cases. The MCH center should be a center for the managment of all pregnancies occurring in the community and the promotion of FP with a systematic and effective linkage of resources available in the county such as i.e. Village Health Worker, Community Health Practitioner, Health Sub-center Physicians & Health workers, Doctors and Midwives in MCH center, OBGY Specialists in clinics & hospitals as practiced by the Seosan project at primary health care level.