Journal of Preventive Medicine and Public Health

Volume 20(1); May 1987

Original Articles

Effects of Anticancer Agents on Cell Cycle Kinetics and Sister Chromatid Exchanges in Cultured Human Lymphocytes.: In Dam Hwang, No Suk Ki, Won Kihl Park, Young Oh Kim, Jeong Sang Lee; Korean J Prev Med. 1987;20(1):1-9.

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Abstract PDF: Sister chromatid exchanges (SCEs) observed by means of bromodeoxyuridine substitution and fluorescence plus Giemsa (FPG) technique were proposed as a sensitive and quantitative assay for mutagenicity and cytotoxicity in short-term cultures of phytohaemagglutinin (PHA)-stimulated human lymphocytes. Therefore, this study was carried out to investigate the relation between anticancer agents and cytotoxic effects. Chromosomal analysis was performed on metaphase cells that had divided one, two, or three or more times after treatment for SCEs, mitotic indices (MI) and cell cycle kinetics by FPG technique. The results indicate that anticancer agents led to a dose dependent increase in SCE frequency except methotrexate. But, highly inhibited mitotic indices and delayed cell cycle kinetics were observed except for cyclophosphamide. The author suggest that the difference of SCE frequency is due to the differences in the cytotoxic action of anticancer agents, but although the induction of SCEs has a correlation with cell cycle delay, in some cases the induction of SCEs is not always related to cell cycle delay because of different cytotoxic action of anticancer agents.; Summary

A Study on the Cause of Death of School Teachers in Korea.: Sung Kwan Lee; Korean J Prev Med. 1987;20(1):10-39.

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Abstract PDF: Mortality rate and causes of death are regarded as an index of strength as well as level of development of a country. However, there is no accurate data for the causes of death in Korea due to lack of systematic vital data collection system. The objective of this study was to define the causes of death of the school teachers, its changing pattern, cause-specific mortality rate, and geographic variation. The study population included all of the teachers in primary school, middle and high schools, and college who joined in Korean Teachers' Union between 1968 and 1985 that provided a total of 1,972,069 person-years to observe (1,384,911 man-years, 587,158 woman-years). There were 3,678 deaths in this period (3,377 males, 301 females). The most common cause of death was neoplasm which was followed by the diseases of circulatory system. The proportion of death of neoplasm was 1.5 times higher than that of the general population. Causes of death were classified into 5 major group (neoplasm, diseases of circulatory system, accidents and poisoning, diseases of liver, and all others). The mortality rates of diseases of circulatory system and all others for general population were 4 to 5 times higher than those for the teachers. However, mortality rates of neoplasm and diseases of liver were only about 2 times higher than those for teachers. Mortality rate of liver cancer for teachers was higher than gastric cancer mortality rate which is the reverse in general population. The crude death rate was 2.12 per 1,000 person-years for male and 1.00 for female which is one-third of the crude death rate of general population. Crude death rate of study population was higher in rural area than in urban area. However, mortality rate of neoplasm for male was higher in urban area than in rural area while mortality rates of all other causes were higher in rural area. For female, mortality rates of neoplasm and diseases of circulatory system were higher in urban area and the rates for all other causes were higher in rural area. Crude death rate was lowest in Gyeongin area and highest in Yeongnam area. The mortality of neoplasm for male accounted the highest proportion of all death in Gyeongin, Chungcheong and Yeoungnam areas while the mortality of neoplasm and mortality of circulatory system accounted the same proportion in Jeonra area. For female, the mortality of disease of circulatory system accounted the highest proportion in Gyeongin and Yeoungnam and Jeonra areas. Proportion of death due to accidents and poisoning was high in Chungcheong area and death due to all other causes was high in Yeoungnam area. The most common cause of death for male by city and province was neoplasm in Seoul, Pusan, Daegu, Gyeonggi, Chungnam, Chungbuk, Gyeongnam and Gyeongbuk. Diseases of circulatory system was the leading cause of death in the rest of city and provinces. The leading cause of death for female was diseases of circulatory system in Seoul, Incheon, Chungbuk, Chungnam, and Gyeongbuk, neoplasm in Pusan, and accident and poisons in all other cities and provinces. The mortality rates of male were above 2 per 1,000 person-years in Jeju, Gyeongbuk, Gyeongnam, Daegu, and Chungbuk, and it was below 1.5/1,000 in Seoul, Incheon and Gyeonggi. The mortality rate of female was above 1.2/1,000 person-years in Gyeongnam and Incheon while it was below 0.5/1,000 in Daegu, Geonggi Chungbuk and Jeju. The leading cause for male by school of employment was neoplasm in all levels of school with a remarkably higher rate in the professors of college. Leading cause of death for female was disease of circulatory system in primary schools, high schools and college but neoplasm in middle schools. There was no death due to liver diseases in middle and high school teachers and college professors and no death due to all other category in igh school teachers and college professors, in females. High school teachers and the highest mortality rate and college professors showed the lowest mortality rate. Temporal trend of mortality was examined in three periods; period I (1968-1974), period II (1975-1979), and period III (1980-1985). The leading cause of death for male was diseases of circulatory system in period I and II but neoplasm in period III. Such trend of decreasing diseases of circulatory system and increasing neoplasm was observed in female. Overall mortality rate was decreased over the 3 periods. The mortality rates of diseases of circulatory system, liver disease and all others were decreased in male but the mortality rates of neoplasm and accident and poisons was increased. Female showed a similar trend to male but the mortality rate of liver diseases was increased. Mortality rates of diseases of circulatory system, neoplasm and liver diseases increased with age of teachers up to 50 years of age but decreased in 60 years of age. Mean age at death due to each cause was higher in male than female by 4-10 years. However, the mean age at death of the teachers was 2-5 years lower than that of the general population in all causes of death and the sex difference in the mean age at death was smaller (2-3 years) in general population. In sex ratio of mortality, male was higher than female in almost all diseases except suicide and maintained a high ratio. The general population showed universally high ratio in male like teachers, and more or less did regular patterns in mortality with ratio smaller.; Summary

A Simulation Model for Strategic Planning in a Community Hospital.: Ki Hong Cheun; Korean J Prev Med. 1987;20(1):40-48.

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Abstract PDF: In this paper strategic planning is applied for effective management to improve hospital income. Though community hospital has been set up for improving the health status of community, it must be trying to increase income for continuing with referral hospital in the community. The most useful tool of management to do this purpose is thought of strategic planning. Therefore this paper developed strategic planning a typical community hospital, which for it presenting the strategic planning process and developing the simulation model for evaluation of strategic alternatives. In the result it is represented that admission rate is the most sensitive to hospital operating income among the important variables in the model. And simulation by changing the parameter could estimate the yearly hospital income in the response of alternatives. This strategic planning simulation model has had constraints as number of date but also significant such as evaluating the alternatives by quantitative model and at first applying the hospital in our country.; Summary

A study on the Heavy Metal Concentrations and Their Interrelationships in Women's Blood and Urine in small towns.: In Dam Hwang, No Suk Ki, Jae Hyung Lee, In Seo Park; Korean J Prev Med. 1987;20(1):49-55.

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Abstract PDF: The results of this study which had been investigated for the purpose of analyzing heavy metal concentrations in women's blood and urine, their correlation degree and significance of cadmium as indicator of accumulated heavy metals are as follows. 1) In blood, concentrations of Cd, Pb, Cu and Zn are respectively 0.0110+/-0.14 ug/ml, 0.208+/-138 ug/ml, 0.899+/-0.153 ug/ml and 5.432+/-1.020 ug/ml. 2) In urine, concentrations of Cd, Pb, Cu and Zn are respectively 0.003+/-0.12 ug/ml, 0.025+/-0.18 ug/ml, 0.013+/-0.12 ug/ml and 0.277+/-0.192 ug/ml. 3) Correlation coefficients between blood and urine are only significant in Zn (r=0.363, p<0.01). 4) In blood, correlation coefficients of Cd concentration and Pb, Zn are respectively 0.518 (p<0.01). 5) Correlation coefficients between Cd concentration in blood and Pb, Cu and Zn in urine are respectively r=-0.012, r=0.027, r=0.241 (p<0.05), and only Cd concentration and Zn is significant.; Summary

Factors Affecting Productivity of Medical Personnel in Training Hospital.: Myung Keyn Lee; Korean J Prev Med. 1987;20(1):56-66.

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Abstract PDF: Information on productivity of hospital personnel is required for optimum staffing and hospital management. This study deals with the quantitative aspects of workload of medical personnel in training hospitals by their specific characteristics. Specifically this study attempted to fine relevant determinants of the productivity of medical personnel using multiple stepwise regression analysis based on data obtained from 135 training hospitals. The findings of this study were as follows: 1) Daily average number of outpatients and inpatients treated by a physician were 20.4 and 10.2, respectively. 2) Daily average number of patients cared by a nurse was 8.2. Daily average number of tests performed by pathologic technician and radiologic technician were 83.2 and 21.5, respectively. 3) Productivity of medical personnel were significantly different for the three groups of factors: hospital size (number of beds, number of medical personnel per 100 beds); institutional characteristics (medical school affiliation, training type, profit status); and environmental factors (location, number of physician and beds per 1,000 population in the region). 4) The factors affecting the productivity varied according to the types of medical profession: the number of beds, the number of physicians per 100 beds, training type, and profit status for physicians; the number of nurses per 100 beds, the number of beds, medical school affiliation for nurses; the number of physicians per 100 beds, the number of technicians per 100 beds, and ownership for pathologic technicians; the number of technicians, training type, and the number of physicians per 100 beds for radiologic technician.; Summary

Determinants of Organizational Performance in the Christian Hospitals.: Yong Ho Lee; Korean J Prev Med. 1987;20(1):67-83.

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Abstract PDF: This study relates to the problems of organizational performance in the Christian hospitals. In this study, quality of working life (QOWL), which harmonizes individual as well as organizational goals, was used as an indicator of organizational performance from the open systems view. In order to identify the behavioral factors influencing QOWL in hospitals, self-administered questionnaires were distributed to 1,926 employees who were randomly selected from fifteen Christian hospitals from August 1 to August 30, 1986. The following results were obtained: 1) All correlation coefficients between QOWL and behavioral variables were statistically significant even though their magnitude varied according to hospital size. 2) Using factor analysis, 32 variables were parsimoniously grouped into four factors: individual conflicts, group behavior, organizational characteristics and situation, and job characteristics. The proportion of variance explained by these factors ranged from 33.5% to 38.6% according to hospital size. 3) The overall effects of the four factors in the multiple logistic models ranged from 0.85 to 3.12 according to hospital size. Among three hospital models, the model for small hospitals showed the best statistical fit. 4) The most influential factor was organizational characteristics and situation with an odds ratio ranging from 1.99 to 3.02. Again, the odds ratio was the highest for small hospitals. 5) For large hospitals, the two main factor effects were statistically significant: organizational characteristics and situation, and job characteristics. For medium hospitals, all main factor effects except job characteristics were statistically significant. For small hospitals, all main factor effects except group behavior were statistically significant. However, a factor interaction effect was shown only for large hospitals where it was statistically significant. 6) To examine whether the four factors influence financial performance, the four factor scores from the two financial performance groups were compared using Mann-Whitney test. The test results showed that the organizational characteristics and situation factor score was significantly different only for small hospitals.; Summary

An Analysis of Deaths Caused by Cancer in Metropolitan Areas of Korea: Seoul, Pusan, Taegu, Incheon.: Chae Un Lee, Joon Youn Kim; Korean J Prev Med. 1987;20(1):84-96.

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Abstract PDF: For the purpose of preparing the basic data for further cancer epidemiologic study and cancer patients control, we conducted the analysis on the degree and structure of deaths from cancer in metropolitan areas of Korea with 7,934 certified cancer deaths records of Seoul, Pusan, Taegu and Incheon in 1982. The analyzed results were as follows : 1) The total number of cancer deaths in metropolitan areas were 7,934 (male: 4,749, female: 3,185) as 14.1% of deaths from all causes in the same area. 2) The rate of physician's certification on cancer deaths was 77.4% and most of cancer deaths (84.4%) occurred at their home. 3) Cancer specific death rate was 51.7 per 100,000 population (male: 62.9, female: 41.9) and age-adjusted cancer death rate was 82.4 in male and 51.6 in female per 100,000 population. And the difference was statistically significant (p<0.01). 4) Age-specific cancer death rate was generally increased with age and most of cancer deaths (male: 75%, female: 65%) occurred from 45 to 74 years old. 5) The first three orders of cancer site were stomach (32.7%), liver (28.8%), lung (11.7%) in male and stomach (30.6%), uterus (18.4%), liver (13.8%) in female. And the relative frequency of these three cancer sites among total cancer deaths was corresponded to 73.2% in male and 62.8% in female. 6) The ratio of male to female cancer death rate was 1.5:1. And the ratio was above 3.0 in esophagus, liver, larynx, bladder cancer and the ratio was similar to 1.0 in stomach, pancreas, leukemia, brain, colon cancer, but the ratio was reversed in gall bladder and bile duct, and thyroid cancer.; Summary

A Semi-longitudinal Study on Physiques and Nutritional Status of Korean Youth in a Seoul Special City.: Tai Young Yoon; Korean J Prev Med. 1987;20(1):97-113.

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Abstract PDF: This study was carried out to know physical growth and development, physical and nutritional indices and body fat weight and so forth by semi-longitudinal research method to measure body height, body weight, chest girth and sitting height of 260 of general high school and 306 of vocational high school 3rd grade students who are living in Seoul and born from 1966 March 1st to 1967 Feb. 28th. The results are as follows; 1) Physical growth and development. Growth in terms of body height showed one step straight linear development, and that of body weight showed two step straight linear development in each section in high school. The age of cross over between two sexes of general high school students was between 10.6 to 12.3 years in body height, between 10.8 to 13 years in body weight, between 11.2 to 14.6 years in chest girth and between 10 to 13 years in sitting height. The age of cross over between two sexes of vocational high school students was between 10.5 to 12.5 years in body height, between 10.5 to 12.5 years in body weight, between 10.5 to 12.5 years in chest girth and between 10.5 to 12.5 years in sitting height. In this periods, female group was superior to male group and after that male group was superior to female group again. The growth of vocational school students was superior to that of general school students in both sexes in terms of body height and body weight significantly. 2) Physical growth and nutritional indices. In all cases of relative body weight, relative chest girth and relative sitting height, it was found to be increasing thereafter with advancing ages. In cases of R hrer index and Kaup index, it was found to be reaching to normal state thereafter with advancing ages. In each case of Vervaeck and Pelidisi index, it was found to be increasing and reaching to normal state thereafter with advancing ages. 3) Total body fat by vital measuring method. Average values of body surface area, body volume and body density are measured indirectly by using the body height and body weight as Table 12, 13 and 14. The rate of body fat weight of general high school students was from minimum 11.96+/-3.53%(3.33+/-1.10 kg) to maximum 18.25+/-6.46% (9.08+/-2.01 kg) in male and from 25.88+/-3.62% (7.96+/-0.78kg) to 43.00+/-7.22% (12.91+/-1.21 kg) in female. The rate of body fat weight of vocational high school students was from minimum 11.20+/-2.88% (3.32+/-1.13kg) to maximum 17.16+/-5.88 (10.83+/-3.16 kg) in male and from minimum 25.11+/-2.26% (7.91+/-0.89 kg) to maximum 42.16+/-7.96% (13.22+/-1.75 kg) in female.; Summary

A Study on the Validity of Passive Hemagglutination (PHA) Test for HBsAb.: Byung Joo Park; Korean J Prev Med. 1987;20(1):114-119.

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Abstract PDF: The author investigated the effect of some variables such as age, sex and the experience of past vaccination on the validity of PHA. The changing pattern of the validity with the change of PHA diagnostic criteria, and the relationship between PHA test result and RIA Ratio Unit were also studied. The results obtained were as follows; 1) No statistically significant difference was found in sensitivity, specificity and negative predictability by sex, but positive predictability was significantly higher in male than that in female. 2) Positive predictability was shown to become higher with the increase of age and negative predictability was found to be significantly different among age groups, but no statistically significant difference was found in sensitivity and specificity by age group. 3) Significantly low specificity and high positive predictability were found in past vaccined group, but no statistically significant difference was found in sensitivity and negative predictability between past vaccined group and non-vaccined group. 4) False negative cases by PHA were found to be the weak positive reactors by RIA and false positive rate of PHA was as high as 46.3 percent. 5) Sensitivity and specificity of PHA at the diagnostic criteria of HBsAb titer 1 : 2 were 98.4% and 53.8% respectively, but after increasing the HBsAb titer to 1 : 64 as the diagnostic criteria the results were 60.0% and 95.6% respectively.; Summary

A Study on the Spectacles-wearing in Korea.: Seung Hum Yu, Yong Ho Lee, Woo Hyum Cho; Korean J Prev Med. 1987;20(1):120-128.

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Abstract PDF: To assess the proportion of spectacles-wearing and an aspect of familial aggregation of myoptic spectacles-wearing and to observe the birth cohort for myoptic spectacles-wearing, a nationwide self-administered questionnaire survey was conducted from March 11 to September 19, 1985. A probability sample of 13,346 persons was taken from 180 enumerated districts designated by the fifth nationwide tuberculosis prevalence survey from Korean Institute of Tuberculosis. The major findings of this survey are as follows: 1) Total of 62.5% of the study population lived in urban area whereas 37.5% lived in Eup-Myun area. There was statistically significant difference in age and sex distribution between two residential area. 2) The percentage of spectacles-wearing was 8.3% and among these, myoptic and hyperoptic spectacles were 6.0%, 2.3%, respectively. A total of 8.8% of the male study population wore spectacles and this was slightly higher than the female (8.0%). 3) Among the occupational groups, students were the highest myoptic spectacles-wearing group whereas professionals were the highest hyperoptic spectacles-wearing group. 4) The proportion of myoptic spectacles-wearing was higher in female students than in male students respectively 11.6%, 8.7%. There was an increasing tendency of spectacles-wearing as age increased. 5) The age-sex adjusted prevalence rate of myoptic spectacles-wearing by residential areas was 2 times higher in urban area than Eup-Myun area. 6) A wearing of the myoptic spectacles in early age was observed in recent birth cohort than remote birth cohort. 7) There was a tendency of familial aggregation for myoptic spectacles-wearing. The proportion of myoptic spectacles-wearing was 6 times higher for those who had parents wearing spectacles. 8) 60.9% of the total myoptic spectacles-wearing persons received the eye-specialist's order and 44.9% for the hyperoptic spectacles wearing.; Summary

Hepatitis B Virus Infection Rate of Medical School Students in Taegu.: Jung Han Park, Tae Hyum Youn, Byung Yeol Chun, Jung Hup Song; Korean J Prev Med. 1987;20(1):129-136.

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Abstract PDF: To determine the hepatitis B virus infection rate of medical school students and appropriate time for immunization with hepatitis B vaccine, 385 students in the 1st, 2nd and 3rd grades of Medical School of Kyungpook National University who had not been vaccinated and volunteered to participate in this study were tested for HBsAg, anti-HBs and anti-HBc with radioimmunoassay method (Abbortt Lab. kit). A questionnaire was administered to ask the history of transfusion, acupuncture and surgery. HBsAg positive students were retested 16 months after the initial test. Overall HBsAg positive rate was 6.8% and the age adjusted rate for male (7.2%) was higher than that for female (4.9%). Anti-HBs positive rate was 35.8% (36.1% for male, 37.9% for male) and anti-HBc positive rate was 45.5% (46.5% for male, 44.7% for femaleP. Overall hepatitis B virus (HBV) infection rats was 49.1% and the infection rate for male (50.3%) was slightly higher than that for female (46.5%). HBsAg positive rate and infection rate were increased as the grade increased but it was attributed to the age distribution of the students. HBsAg positive rate for 20 years old students was 1.7%; 21 years, 6.6%; 22 years, 6.1%; 23 years, 12.2%; and 24 years and older, 6.4%. HBV infection rate showed an increasing trend as age increased; 45.8% for 20 years, 41.5% for 21 years, 49.5% for 22 years, 55.5% for 23 years and 59.6% for 24 years and older. The age differences in HBsAg positive rates and HBV infection rates did not reach the statistical significance level of 0.05. However, these findings and similar age differences in HBsAg positive rates and HBV infection rates observed in other study suggest that there is a significant age differences. Study of the same age group in other schools and different social classes is warranted to confirm the age difference. Clarification of the reason for such differences would provide a clue to identify the major route of HBV transmission in this age group. Among 26 HBsAg positive students in the initial test, only one student was active hepatitis patient. Out of 24 students who had follow-up test after 16 months 22 students were positive for HBsAg and two students became HBsAg negative and anti-HBs positive. It is obvious that nearly one-half of the medical school students were infected with HBV before 20 years of age and the HBV infection occurs in medical school. Thus, it is recommended to test all the students for HBV infection soon after the admission to the medical school and immunize all the susceptible students with hepatitis B vaccine and give booster as they start to practice at a hospital.; Summary

Epidemiological Trend of Japanese Encephalitis in Korea.: Chu Won Lee, Dae Kyu Oh; Korean J Prev Med. 1987;20(1):137-146.

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Abstract PDF: The following facts have been identified as a result of epidemiogical trend and characteristic of Japanese Encephalitis in Korea for the last 20 years. First: The Epidemiological period which was ten-year and three-year in the past has been disappeared following the start of immunization program at 1970. Second: The incidence rate was much higher in the south and West areas than northeast area of Korea. City and province with the highest incidence rate was Chungcheong Nam Province and Cholla Buk Province. Third: Regardless of scope of prevalence, the main season that 90 percent of total incidence occurs in one month from mid-September. Fourth: The number of case by age was that 80 percent of total patients is children aged 3-15. Recently there is an increase in the number of patients who are elderly people. Fifth: The study on the ecological conditions of mosquito including wintering and effectiveness of immunization for Japanese Encephalitis and duration on antibody should be done. Sixth: There has been no case of Japanese Encephalitis during last three years since 1984 mainly due to disinfecting to eradicate mosquitos, immunization for vulnerable group of people aged 3-15, individual precaution not to be bitten by mosquito, improvement sanitation. While there has been no case of Japanese Encephalitis during last three years, there is possibility that Japanese Encephalitis becomes prevalent again anytime since its virus has been isolated continuously from the natural reservoirs.; Summary

The Investigation on Results from Health Examination of Partial Healthy Public Officials and Private School Teacher in Daegu.: N K Yoon, S K Suh; Korean J Prev Med. 1987;20(1):147-157.

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Abstract PDF: Authors obtained the results of the investigation for healthy people through the routine health examination of public officers and school personnels in private schools which were conducted in 1986. The results were as follows; 1) Those who were above 20% incidence of body weight for 3917 study population were revealed 5.2% in males and 15.1% in females of 45-49 years of age, 6.8% in males and 24.4% in females of 50-54 years old, 5.8% in males and 13.5% in females of 55-59 years old, and they showed that the incidence were significantly higher in females than in males at 0.01, 0.01 & 0.05 in P-values respectively. 2) Mean+/-SD of total cholesterol level for 3,265 healthy people with both sexes combined showed 181.63+/-34.67 and it was 188.61+/-33.96 in people of 40-59 years old with both sexes combined. Mean+/-SD of fasting blood sugar level for 3,266 healthy people showed 87.28+/-11.67 and that in 40-59 years of age were 89.14+/-11.74. Therefore, mean+/-2SD of total cholesterol and fasting blood sugar were 112.26-250.98mg/dl in males and 58.93-110.61 mg/dl in females. 3) This investigagion showed 3.0% in above 251 mg/dl of total cholesterol and 3.5% in above 111 mg/dl of fasting blood glucose. 4) Those who were above 251 mg/dl of total cholesterol and above 111 mg/dl of blood glucose in above 20% incidence of body weight according to the Broca' index were 12.9% and 7.6% respectively. 5) Those who have hypertension according to the criteria of WHO with obesity of above 20% incidence of body weight showed 8.4% in both sexes (8.2% in males and 8.7% in females). 6) Blood pressures increased according to more aging and gainin body weight.; Summary

A Study on Occupational History of Coal Workers' Pneumoconiosis.: Ho Keun Chung, Yong Hee Cheon, Kyung Young Rhee, Jeong Pyo Hong; Korean J Prev Med. 1987;20(1):158-164.

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Abstract PDF: The purpose of this study is to analyze occupational history of coal miners with pnemoconiosis. In this study, occupational chracteristics of 49 coal miners with pneumoconiosis were compared with those of 45 coal miners without pneumoconiosis but in similar age category (43-52 years of age) based on interview survey. Various indices on occupational characteristics were developed for the following areas: duration of employment, perception of working condition, working density, dust concentration, temperature, humidity, and experience of respirator wearings. Perception of working condition were measured in 5 points scales but experiences of respirator wearing was measured in 3 points scale. Each index was multiplied by duration of employment. From the analysis, only the experience of respirator wearing showed statistically significant difference between the two groups. Therefore, respirator wearing seemed to be effective in reducing occurrence of pneumoconiosis.; Summary

An Intervention Study on Integration of Family Planning and Maternal/Infant Care Services in Rural Korea.: Sook Bang, Seung Hyun Han, Chung Ja Lee, Moon Young Ahn, In Sook Lee, Eun Shil Kim, Chong Ho Kim; Korean J Prev Med. 1987;20(1):165-203.

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Abstract PDF: 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 medically supervised deliveries, (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. Neverthless, 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 "intergration 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, sltructure, 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 78% 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%) & delivery care (45.2% vs. 26.1%). 4. The study area had better reproductive efficiency (wanted pregnancies 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 carrying 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, 85-90% of the services provided by the health workers were other than FP/MCH, mainly for immunization 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 (ADMINISTRATIVE 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 midwives'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 planning practice. 2) Goal consensus in FP/MCH should be made among the health workers & 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, (ii) 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 management 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 Workers, 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.; Summary

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