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Please use this identifier to cite or link to this item: http://hdl.handle.net/10285/1390

NII Resource type: Thesis or Dissertation
Title: ミャンマー連邦農村の母子保健向上をめざす女性保健ボランティア育成プログラムの評価
Other Titles: Evaluation of the development program for women health volunteers of reproductive and child health at the community level in union of Myanmar.
Authors: 小黒, 道子
Advisor: 堀内, 成子
Keywords: ミャンマー連邦
母子保健
参加型アプローチ
lay health worker
発展途上国
国際保健
人材育成
Issue Date: Mar-2008
Abstract: Ⅰ.序論 1.研究の背景  今日、世界における妊産婦死亡は年間50万人を超え、その犠牲者の多くは発展途上国(以下、途上国とする)に生きる女性である。近年は当事者や地域社会を主体と捉え、途上国の女性を組織化し、女性自身が問題を話し合い解決を図る参加型アプローチの有効性が報告されている。 研究者は、2003年4月から2004年8月まで、国際医療NGOの母子保健専門家としてミャンマー連邦(以下、ミャンマーとする)に派遣され、2003年9月より試験的にマンダレー管区メティーラ市の2つの農村において、地域母子保健向上を目指す女性保健ボランティア育成プログラム(以下、プログラムとする)の開発に携わった。プログラムは、用件を満たした女性から成るヘルス・ボランティア・グループ(Women’s Health Voluntary Group、以下WVGとする)を参加型アプローチで育成する、地域母子保健の向上を目的とした住民組織化の過程を指す。 プログラムは2003年9月から2008年3月をⅠ期(創設期)、Ⅱ期(維持・継続期)、Ⅲ期(自立期)に分類し、4年半でWVGが自立した活動を行うことを目標とした。 WVGとの対話により明らかとなった学習意欲・準備状態を考慮したプログラム運営により、WVGは徐々に言動が変化し、エンパワーされた様相が認められた。活動項目は、1)経済的に受胎調節が行なえない女性を対象に無利子で資金を貸与する「家族計画基金」の運営、2)妊婦や乳幼児の母親に対する健診や予防接種の必要性の説明および受診への付き添い、3)周産期の異常症状の早期発見・対処、4)負傷者の応急手当て、5)住民への保健衛生教育、であった。 2008年3月の外部者支援終了後も当事者による活動の発展的継続を目指すには、プログラムの評価を行う必要がある。 2.研究目的  ミャンマー農村部における妊産婦の保健環境の改善を目指す女性保健ボランティア育成プログラムを評価する。これによりミャンマー農村部におけるLay expert活用による健康生成方略への具体的提言を行なう。 3.研究目標 1)ミャンマー農村部における女性保健ボランティア育成プログラムの成果として住民女性の保健に関する知識および意識を明らかにする。 2)ミャンマー農村部における女性保健ボランティア育成プログラムの成果としてWVGの変化を記述する。 3)ミャンマー農村部における女性保健ボランティア育成プログラムの成果としてWVGの活動に対する住民の満足を明らかにする。 4.概念枠組み 本研究の概念枠組みは、Rush& Ogborneのプログラムの論理モデルを参考に作成された。プログラムの開発(Input)によりWVGが組織化(Output)され、外部者支援を受けたWVGがサービスを住民に提供した(Process)結果、①住民女性の保健に関する知識および意識が改善し、②WVGもプログラムがもたらした経験により変化する、それと同時に③住民もサービスに満足する(以上、①~③がOutcome)、と考え、本プログラムの評価とした。 Ⅱ.研究方法 1.研究デザイン 横断型のプログラム評価研究デザインを用いた。 2.データ収集方法 1)住民女性の保健に関する知識・意識 (1)研究対象 対象は無作為標本抽出とし、プログラム介入村及びコントロール村に居住する15~49 歳で5歳以下の子どもを持つ女性のうち条件(ミャンマー語での会話が不自由でない、重篤な精神疾患を持たない)を満たすものとした。標本数の算定は変数×10とし、変数をWVGの活動項目(家族計画、妊婦健診及び妊娠中の予防接種促進、周産期の異常、負傷時の応急手当、保健衛生教育)として5と考え、1ヶ村50人の合計4ヶ村で200名とした。 (2)データ収集方法及び内容 データ収集方法は質問紙を用いた構成的面接調査で、WVGが提供したサービスに関する住民の知識・意識を問う内容とした。測定用具は、女性と子どもの状況をモニタリングするために開発されたUNICEFの重要指標クラスター調査に基づき、本研究の目的に合致した計102項目(対象の背景31、家族計画10、妊婦健診及び妊娠中の予防接種16、周産期の異常9、負傷時の応急手当3、保健衛生教育33)の質問票を作成した。質問項目の内容妥当性は、国際保健活動の経験がある看護学修士号以上の学位を持つ助産学研究者2名と検討し、同意が得られた項目を採用した。 (3)データ収集場所 場所は、ミャンマー・マンダレー管区メティーラ市ニャウンザ村及びチャオプー村と、コントロール村として社会経済状況の類似したI村及びS村の合計4か村で行った。 (4)研究手順 研究手順は、集落図に基づき研究対象者の標本抽出台帳を作成し、乱数表を用いて無作為抽出した。研究協力者が該当者の自宅を訪問し趣旨を説明後、参加の同意を得たら調査日時を調整した。識字への配慮として、対面式で研究協力者が回答を記載した。 (5)データ分析 分析にはSPSSver.15.0を使用し、基本統計量を算出した。プログラム介入村とコントロール村の比較には、Mann-WhitneyのU検定、カイ二乗検定、Fisherの正確検定を行なった。有意水準は5%未満とした。 2)WVGの変化 (1)研究対象 対象は、WVG、プログラム関係者(保健職員、村長)及びWVGの家族が全員、そして雪玉式に抽出されたWVGのサービスを受けた住民10名程度で、条件(ミャンマー語での会話が不自由でない、重篤な精神疾患を持たない)を満たすものとした。 (2)データ収集方法及び内容  データ収集方法はインタビューガイドを用いた半構成的面接で、プログラムによるWVG自身の変化、周囲との関係の変化、そして副次的な効果、を問う内容とした。面接はテープ録音され、逐語録が作成された。 (3)データ収集場所 場所は、プログラム介入村であるニャウンザ村及びチャオプー村で行った。 (4)データ分析  データはKrippendorfの内容分析の方法を参考に、①逐語録を反復して読み、「プログラムによるWVGの変化」に関する各語りの内容を記録単位として抽出、②単位における意味的特性を推論し、文脈的に同義と判断できるものを文脈的表象として集積、③類似した文脈的表象を整理後説明概念を作成、④説明概念をカテゴリにまとめ、「WVGの変化」を説明した。 3)住民の満足 (1)研究対象 対象は、雪玉式に抽出されたWVGのサービスを受けた住民10名程度と関係者(保健職員、村長)で、条件(ミャンマー語での会話が不自由でない、重篤な精神疾患を持たない)を満たすものとした。 (2)データ収集方法及び内容 データ収集方法はインタビューガイドを用いた半構成的面接で、WVGによるサービスの感想、問題点、要望を問う内容とした。面接による対象者の負担を軽減するため、2)WVGの変化、に関する面接と同時に行なわれた。面接はテープ録音され、逐語録が作成された。 (3)データ収集場所 場所は、プログラム介入村であるニャウンザ村及びチャオプー村で行った。 (4)データ分析 データは質的帰納的に分析した。①逐語録として集積したインタビューデータを、「WVGメンバーおよびWVGの活動に対する思い」に関する語りの内容を一つの記録単位とした。②単位における意味的特性を推論し、文脈的に同義と判断できるものを文脈的表象として集積した。③類似した文脈的表象を整理して説明概念を作成した。④説明概念をカテゴリとしてまとめ、WVGの活動への住民の満足を説明できるものとした。   なお、データ収集期間は2007年2月から7月で、すべてのデータは、訓練を受けたミャンマー人の研究協力者がミャンマー語で収集した。面接記録は、すべて日本語能力検定2級以上のミャンマー人翻訳者が日本語に翻訳した。 3.倫理的配慮 本研究における倫理的配慮は、無害の原則、自由意志での参加、匿名性の保持、途中辞退の自由、プライバシーの保護、個人情報守秘の厳守、成果発表時の個人情報の保護など倫理原則に則って行なわれた。また、本研究は、研究計画書の段階で聖路加看護大学研究科倫理審査委員会の承認(承認番号:06-072)及びミャンマー政府の承認を得て実施した。 Ⅲ.結果 1.住民女性の保健に関する知識・意識 1)対象の基本的特性  ニャウンザ村50名とコントロールのI村50名、チャオプー村50名とコントロールのS村38名の計188名の女性に面接を行った。S村は、対象女性の全数が38名だった。職業は、ニャウンザ村の半数以上が縫製業であったが、他3村は半数以上が農業に従事していた。健康資源として、ニャウンザ村のコントロールであるI村の助産師の背景特性(就業年数15年で家族と定住)が、他3村(就業年数3年以下で独身)に比し特徴的であった。以下、ニャウンザ村とコントロールI村を街近群、チャオプー村とコントロールS村を街遠群として結果を述べる。出産歴は、街遠群で介入村がコントロール村より平均初産年齢が若く(z=-2.56, p=.01)、平均出産回数(z=-2.05, p=.002)が多かった。その他の基本的特性は介入村とコントロール村で差は認められなかった。 2)面接結果 (1)妊娠・出産ケアの促進  妊娠中少なくとも1回は妊婦健診を受診した女性の比率は、街近群はコントロール村が高く(χ2=15.17, p=.000)、街遠群は介入村が高かった(χ2=24.43, p=.000)。 妊娠時、破傷風の予防接種を2回以上受けた女性の比率は、街近群はコントロール村が高く(χ2=13.71, p=.000)、街遠群は差が認められなかった(χ2=.91, p=.38)。 訓練を受けた技能者(Skilled Birth Attendant, 以下SBAとする)と出産した女性の比率は、街近群ではコントロール村が高く(χ2=29.68, p=.000)、街遠群は差が認められなかった(χ2=2.98, p=.08)。 (2)周産期各期の危険症状の早期発見 周産期の危険症状の知識は、介入村がコントロール村よりも高かった。妊娠期、出産期、産褥期、新生児期すべてにおいて、街近群[{妊娠期(z=-2.76, p=.006)}、{出産期 (z=-4.52, p=.000)}、{産褥期 (z=-5.49, p=.000)}、{新生児期 (z=-3.48, p=.001)}]も、街遠群[{妊娠期(z=-7.25, p=.000)}、{出産期(z=-6.82, p=.000)}、{産褥期(z=-7.03, p=.000)}、{新生児期(z=-7.06, p=.000)}]も介入村の方が知っている知識の平均値が高かった。 (3)家族計画基金の運営  近代避妊法の知識は、介入村がコントロール村より高かった{街近群(z=-4.25, p=.000)、街遠群(z=-7.48, p=.000)}。  しかし、「避妊法利用者」および「最後の妊娠が望まない妊娠」だった比率は、介入村とコントロール村で差は認められなかった[{「避妊法利用者」:街近群(χ2=.438, p=.508)、街遠群(χ2=2.30, p=.13)}、{「望まない妊娠」:街近群(χ2=1.51, p=.37)、街遠群(χ2=2.55, p=.20)}]。 (4)負傷者の手当  説明可能な応急処置法を回答する女性の比率は、「切傷」、「火傷」、「犬の咬傷」のいずれも介入村がコントロール村に比べて高かった [{「切傷」:街近群(χ2=53.91, p=.000) 、街遠群(χ2=42.90, p=.000)}、{「火傷」:街近群(χ2=9.19, p=.006)、街遠群(χ2=35.20, p=.000)}、{「犬の咬傷」:街近群(χ2=33.43, p=.000)、街遠群(χ2=26.13, p=.000)}]。 (5)保健衛生教育(5歳未満の子どもへの疾病対処法、マラリア予防、水と衛生) 過去2週間で発熱を伴う病気を発症した患児の比率は、街近群はコントロール村が高く(χ2=8.39, p=.004)、街遠群は差が認められなかった(χ2=4.22, p=.066)。発症中に受診行動を起こした比率は、街近群でコントロール村が介入村より高かった(χ2=5.29, p=.039)。 マラリア予防において、面接前夜に蚊帳で就寝した子どもの比率は、街遠群はコントロール村が高く(χ2=15.56, p=.000)、街近群は差が認められなかった(χ2=.38, p=.538)。蚊帳を使用しない理由は、蚊帳の利用者が50%以下だった街遠群の介入村は、対象者の83%が経済的理由を挙げた。マラリア予防法の知識(8項目)は、街近群(z=-6.25, p=.000)・街遠群(z=-7.65, p=.000)のいずれも介入村が高かった。 水と衛生について、3歳未満の子どもの便の処理法は、街遠群の介入村は適切な処理を回答した女性の比率が高かった(χ2=10.11, p=.002)。街近群は差が認められなかった(χ2=3.407,p=.107)。 3)介入村における第一次基礎調査とOutcome評価の比較  介入村における妊娠・出産に関わる保健行動について、2003年に実施した第一次基礎調査と比較した結果、破傷風の予防接種(ニャウンザ56.4%増・チャオプー44.0%増、以下同順の表記)、SBAとの出産(19.3%増・18.6%増)、そして避妊法利用者(24.6%増・18.4%増)と、各比率が増加していた。 2.WVGの変化 WVG22名、プログラム関係者8名、WVGの家族19名、裨益村民23名の計74名に面接を行った。 WVGの変化を分析した結果、28のサブカテゴリと10のカテゴリが抽出された。WVGの変化は、何もわからない状態からWVGへの参加を契機とした、【日常に活用可能な知識の獲得による行動の変化】を核とする、【知識の獲得から派生した意識の広がり】へと発展していた。変化の過程においては、【村落社会の機能活用】により変化をより合理的に推し進めていた。この変化の過程に直接影響を与えたのは、【家族の支援】と【カネの運用】、そして【モノの存在】であった。これらの変化を支える基盤は、WVGの【参加への動機付け】と【宗教と文化に基づく思想】であった。さらに変化の副次的効果として、【地域が醸し出す感謝の念】という地域の変化と【基礎保健職員との連携】という保健専門職の変化が現れていた。 3.住民の満足  対象者は関係者が8名、住民が25名で計33名であった。  対象者が認知するWVGのサービスは全11項目だった。半数以上の対象者が認知するサービスは、ニャウンザ・チャオプー村ともに、家族計画基金貸与、負傷者の応急手当、保健衛生教育の3項目であった。  WVGの活動への思いを分析した結果、【活動への感謝】の1カテゴリが抽出された。一方、WVGの課題として、【薬剤の取り扱い】、【活動資金創出事業への注文】の2カテゴリが抽出された。WVGへの今後の期待としては、【薬剤の充実】、【活動の維持】、【さらなる活動の拡大】、【健康は生活】の4カテゴリが抽出された。 Ⅳ.考察 1.女性保健ボランティア育成プログラムの成果  周産期の異常症状や避妊法の知識、負傷時の応急手当や保健衛生の知識の獲得及び意識の向上は、プログラム介入村の方が優れていた。WVG育成から足掛け4年を経ているが、初期段階に得た知識が実践され、生きた知識として活用されていることがわかった。介入村に限っては、プログラム開始時の4年前よりも妊娠中の予防接種率およびSBAの出産立会い率も増加していたが、横断調査からは、長年村に居住し、住民に信頼され適時受診可能で支払いも猶予する助産師のいた特定コントロール村(I村)に好成績であるという特徴があった。 この結果は、途上国農村部の母子保健環境改善に2点の示唆を与えている。 1点目は、同じ地域の住民が公式・非公式含めた機会を通じ、母子保健や健康に関する情報や簡単な処置を提供し続けることで、住民一人ひとりの知識や意識の量が格段に高まり、それが持続することである。女性が能力を持つことは、エンパワメントされコミュニティそのものを活性化することにつながっている。長期的な地域の保健環境向上にヘルスボランティア活用の利点があるといえるだろう。 2点目は、母子保健指標の改善には良質の専門家―ここでの良質とは、相応しい教育を受け、利用しやすく地域住民からの信頼が厚いという要素であるが―、その存在が不可欠ということである。ミレニアム開発目標のうち「妊産婦の死亡率を4分の1に削減する 」の指標には、「熟練介助者の立会いによる出産を増やす」ことが含まれる。途上国での医療・保健人材不足が深刻化する中、単に存在するだけではなく専門家の質の保証がないと指標の改善には貢献しない可能性を見出すことができる。経済的・人的資源に制限の在る中、地域で利用可能な資源と当事者のニーズに応じ、テーラーメイドにデザインを描くことが、ひいては途上国の地域母子保健向上の近道となるであろう。 2.女性保健ボランティア育成プログラムによるWVGの変化  すべてのWVGが自身の変化として真っ先に「知識を得た」と語り、それまで知らなかったことを知ることができたことが変化の根源であった。WVGらは、まず外部者との対話を重ねる中で、これまで知る機会のなかった健康に関する知識を獲得するという変化を経験していた。その後、獲得した知識を他者に伝えることで、個人特性や地域における人間関係の改善といった意識の広がりが現れていた。多くのWVGメンバーらは「村人の健康を支援する」という目標をメンバー間、プログラム関係者、そして外部者らといった他者と分かち持つ機会を得たことが【日常に活用可能な知識の獲得による行動の変化】を核とする、【知識の獲得から派生した意識の広がり】へと発展していた。 3.女性保健ボランティア育成プログラムの展望 WVGの活動に対する住民の満足を分析した結果、今後WVGがコミュニティ内で薬剤供給に果たす役割が、プログラムの持続発展性に影響を与えることが示唆された。 Ⅴ.結論 ミャンマー農村部において母子保健向上をめざす女性保健ボランティア育成プログラムの評価を行った。Lay expertとしてコミュニティにある女性たちの育成は、プログラム実施から4年後においても消失することなく活用され、周産期、避妊法、応急手当の知識や衛生意識の向上などコミュニティに好ましい変化をもたらしていた。 また、プログラムはWVGに、何もわからない状態からWVGプログラムへの参加を契機とした、【日常に活用可能な知識の獲得による行動の変化】を核とする、【知識の獲得から派生した意識の広がり】という変化をもたらしていた。  プログラムの展望として、今後WVGがコミュニティ内で薬剤供給に果たす役割が、プログラムの持続発展性に影響を与えることが示唆された。
Abstract-Alternative: I. Introduction 1. Study background Today, more than 500,000 pregnant and parturient women die in the world every year, most of these women living in rural areas in developing countries. A recent report has described the effectiveness of a participatory approach by women’s organization in developing countries, where the residents of a community are the core contributing to solving their own problems. This researcher was sent to Myanmar as a maternal and child health specialist by an international NGO from April 2003 through August 2004, and was engaged in the development of a program for Women Health Volunteers for improving the reproductive and child health of a community of two villages located in Meiktila township of Mandalay division, since September 2003. The Women health Voluntary Program set up a process to develop the Women Health Voluntary Group (WVG), whereby women who satisfied certain requirements were organized in to a group that worked to improve regional maternal and child health using a participatory approach. The Program supported the WVG in creating independent activities in the four and a half year period from September 2003 to March 2008, the total program period being divided into three periods: I (start up), II (ongoing), and III (self-sustainability), according to the status of its progress. The program management, considering the volunteers’ motivation and readiness for learning that became apparent based on communications, gradually and progressively empowered the WVG. The activities of the group included: 1) Management of the fund for Family Planning where women with no financial capability for birth control could borrow money at no interest, 2) Educating and encouraging pregnant women and mothers of babies about the necessity of health checks and immunizations, and attending to them when they have these checks and immunizations, 3) Early detection of abnormal signs and symptoms during the perinatal period 4) Providing first aid for injured people (for injuries sustained in agricultural work, for example), and, 5) Health education for local residents (about 15 families per WVG group member).An ongoing evaluation of the outcome of this program was required to assess the sustainability of the activities of the WVG by the end of the program in March 2008. 2. Study objectives This study aims to evaluate the outcome of the WVG program in rural areas of Myanmar, established to improve the healthcare environment for reproductive-age women. 3. Study goals 1) Exploring whether community women acquired sufficient healthcare knowledge and improved their awareness of health as a result of the WVG Program. 2) Describing the changes in the WVG members themselves as a direct result of the program. 3) Assessing the satisfaction of the community with the program. 4. Conceptual framework This study is based on the logical model of the Rush and Ogborne program (1991), which includes development (Input) of the program and organization (Output) of the WVG. Three aspects of Outcome were evaluated to assess whether through the services provided by the WVG for the community, with support from outsiders, community women could acquire healthcare knowledge and improve their awareness of health-related issues, the WVG members themselves could change by joining the program, and also, peoples’ satisfaction with the WVG’s services. II. Study method 1. Study Design A cross-sectional study design was adopted to allow for evaluation of the program. 2. Data collection and processing 1)Healthcare knowledge and health awareness of women in the community (1) Participants (Selected from among members of the community who benefited from the services of the WVG) Participants were selected by random sampling under the following conditions: -Women between the ages of 15-49 who lived in the intervention villages or control villages of the program and had a child aged 4 years or younger. -Those who were able to communicate in the Myanmar language -Those who had no serious mental illness Five variables were selected for assessment from among the WVG’s activities: family planning, health check and immunization of pregnant women, knowledge of abnormalities in the perinatal period, first aid for injuries, and healthcare education. The number of participants was set to 50 per village, i.e. a total of 200 in the four villages, this number being selected because it was 10 times the number of variables. (2) Data collection method Data was collected in structured interviews using a questionnaire. The questions were developed based on the resident’s knowledge or awareness about the services that the WVG provided. The questionnaire were created to meet the study aim of monitoring the health care conditions of women and children, based on the Multiple Indicator Cluster Survey has been conducted by UNICEF that selectively used appropriate themes from the viewpoint of country, culture, or survey aim. A total of 102 question items were established (31 items on background of the participants, 10 items on family planning, 16 items on health check and immunization of pregnant women, 9 items on abnormalities in the perinatal period, 3 items on first aid for injuries, and 33 items on health education). The validity of the questions were checked by two specialists in this field, and only the question items that were agreed on were included in the questionnaire. (3) Study field Data was collected in four villages: Nyaung-Zak and Kyaouk-Phoo villages in Meiktila Township, Mandalay Division serving as intervention villages, and two other villages with a similar socio-economic standard as Nyaung-Zak and Kyaouk-Phoo, called as I and S villages, serving as control villages for Nyaung-Zak and Kyaouk-Phoo, respectively. Nyaung-Zak and its control village I were together grouped as close-to-town villages (CTT), and Kyaouk-Phoo and its control village S were grouped as far-from-town villages (FTT). (4) Procedure Sampling sheets of study participants were created based on the village map, and participants were selected by random sampling. Study collaborators then visited the participants and explained the aim of the study to them. If and when they obtained the consent of the participants, the collaborators arranged an appointment for an interview. The collaborators filled the questionnaire in consideration of participants’ literacy levels. (5) Data analysis SPSSver.15.0 was used for data analysis. Mann-Whitney U-test, Chi-squared test and Fisher’s exact test were used for comparison between intervention and control villages. The level of significance was set at 5% or smaller. 2) Changes in the WVG members  (1) Participants All the WVG members, people (including healthcare staff, village leaders) who were involved in the program from the intervention villages, families of WVG members, and about 10 residents selected by snowball sampling from among those who received the WVG’s service and who satisfied the participant requirements of ability to communicate in the Myanmar language and absence of serious mental illness, were included as participants. (2) Data collection method Data was collected in a semi-structured interview. Participants were asked to talk about what they felt or thought about the changes in the WVG members, the relationship between the WVG and community people, and subsidiary effects of development of the Program. The interview was taped and used as a literal record. (3) Study field Data was collected in Nyaung-Zak and Kyaouk-Phoo villages, intervention villages of the WVG program. (4) Data analysis Krippendorf’s content analysis method was used as a reference. For evaluation of changes in the WVG, analysis was conducted in the following manner: (i) The interview record was divided into a unit of “personal change due to activities of the WVG” by repeatedly reading the record. (ii) Semantic characteristics were extracted from record unit, and contextual representations of what could be considered as contextually the same were collected. (iii) Explanatory concepts were created by arranging similar contextual representations. (iv) Explanatory concepts were categorized to arrange “the changes in WVG members” into an explainable format. 3) Satisfaction with WVG’s activities (1) Participants All the people in the intervention villages who were involved in the program, (including healthcare staff and village leaders) and about 10 residents selected by snowball sampling from those who received the WVG’s services and who satisfied the criteria of being able to communicate in the Myanmar language and had no serious mental illness, were included as participants in this part of the study. These participants were the same as those who were questioned to evaluate changes in the WVG members. (2) Data collection method Data was collected via a semi-structured interview. Participants were asked what they felt about the services provided, and if they had any concerns and requests for the WVG. The interview was taped and made into a literal record. (3) Study field Data was collected from Nyaung-Zak and Kyaouk-Phoo villages, intervention villages of the WVG program. (4) Data analysis Qualitative-inductive analysis of the data was performed in the following manner: (i) Interview records were divided into units of “thoughts about the WVG and the WVG’s activities.” (ii) Semantic characteristics were extracted from each record unit, and contextual representations of what could be considered as contextually the same were collected. (iii) Explanatory concepts were created by arranging similar contextual representations. (iv) The explanatory concepts were categorized to arrange “the feeling about WVG’s activities” into an explainable format. All data were collected over a period of 6 months from February to July 2007.The data was all translated from Myanmar to English or Japanese with the aid of Myanmar natives who had Japanese language ability on par with the second grade of the Japanese Certificate. 3. Ethical considerations This study was conducted in accordance with the ethical principles of harmlessness, voluntary nature, anonymity and protection of privacy and personal information. It was also approved by St. Luke’s College of Nursing Research Ethics Review Board (approval number: 06-072) and the Ministry of Health, Myanmar. III. Results 1. Healthcare knowledge and health awareness of women in the community 1) Baseline Characteristics Of the 188 women who participated in the study, 38 women were from village “S”, the control village for Kyaouk- Phoo, and 50 women each were from the other three villages. All the people who reside in village “S” in the survey were only 38 women. More than half of the people in Nyaung Zauk were employed in the sewing industry, while the remaining people worked as farmers. Results are grouped as: Nyaung Zauk and I villages in the close-to-town (CTT) group, and Kyaouk-Phoo and S villages in the far-from-town (FFT) group. In terms of the women’s’ reproductive history, age at first childbirth in the intervention village in the FFT group was lower than in the control village (z=-2.56, p= 0.01), the number of childbirths also being larger than in the control village (z=-2.05, p=0.002). Other characteristics were not significantly different within each group. 2) Results of interview (1) Encouraging antenatal and childbirth care With regard to the rate of participants who had received antenatal care at least once during the last pregnancy, the control village of the CTT group had a higher rate than the intervention village (χ2=15.17, p=0.000), while the intervention village of the FFT group had a higher antenatal care rate than it’s respective control village (χ2=24.43, p=0.000). In terms of number of participants who received tetanus toxoid immunization at least twice during the last pregnancy, the control village of the CTT group had a higher immunization rate than the intervention village, there being no difference between FFT group villages (χ2=0.91, p=0.38). The rate of births in the presence of skilled attendants in the control village of the CTT group were higher than those in the intervention village (χ2=29.68, p=0.000), there being no significant difference in FFT group villages (χ2=2.98, p=0.08). (2) Early detection of abnormal signs in the perinatal period During all stages of pregnancy and childbirth, antenatal, natal, neonatal and postnatal, participants in the intervention villages of both CTT and FFT groups were more aware of possible abnormal events. [CTT: antenatal (z=-2.76, p=0.006)、{ childbirth (z=-4.52, p=0.000), postnatal (z=-5.49, p=0.000), neonatal (z=-3.48, p=0.001), and FFT: antenatal (z=-7.25, p=0.000)}、{ childbirth (z=-6.82, p=0.000)}、{ postnatal (z=-7.03, p=0.000)}、{ neonates (z=-7.06, p=0.000)]. (3) Management of the fund for family planning There were no significant differences in the number of contraceptive users in both CTT (χ2=0.438, p=0.508) and FFT groups (χ2=2.30, p=0.13). Intervention village women were more cognizant of the different types of contraceptives as compared to control village women in both CTT (z=-4.25, p=0.000) and FFT groups (z=-7.48, p=0.000). With regards to the number of unwanted pregnancy, there was no significant difference in both CTT (χ2=1.51, p=0.37) and FFT groups (χ2=2.55, p=0.20). (4) First aid The number of first aids for cuts, burns and dog bites that were appropriately administered were higher in the intervention villages as compared to the control villages in both CTT and FFT groups [CTT: cut (χ2=53.91, p=0.000), burns (χ2=9.19, p=0.006), dog bites (χ2=33.43, p=0.000) and FFT: cuts (χ2=42.90, p=0.000), burns (χ2=35.20, p=0.000) and dog bites (χ2=26.13, p=0.000)} (5) Health education (Care for illnesses in children under 5 yrs of age, prevention of malaria and water and sanitation) Significantly more children had suffered from febrile diseases in the 2-week period prior to questioning in the control village of the CTT group (χ2=4.22, p=0.04) as compared to the intervention village. There being no significant difference in FFT group villages (χ2=4.22, p=.066). Significantly more children from the control village sought care during their illness (χ2=5.29, p=.039). For protection against malaria, the number of children who used mosquito nets on the night prior to the survey was higher in the FFT control village as compared to the intervention village (χ2=15.56, p=0.000). There being no significant difference in CTT group villages(χ2=.38, p=.538). Of the more than 50% respondents in the intervention village of the FFT group who did not use mosquito nets, 83% cited being economically challenged as the reason. Intervention villages in both FFT and CTT groups were more knowledgeable about malaria prevention (8 items), as compared to their respective control village counterparts [CTT (z=-6.25, p=0.000) and FFT (z=-7.65, p=0.000)]. In terms of water and sanitation, more appropriate disposal of children's stool was achieved in the intervention village of FFT as compared to control (χ2=10.11, p=0.002). There being no significant difference in CTT group villages (χ2=3.407,p=.107). 3) Comparison with the baseline survey in intervention villages The proportion of appropriate health behaviors in the perinatal period in the intervention villages were also compared with the results of a baseline survey conducted in these villages in 2003. An increase in the number of antenatal immunizations, births attended by skilled health personnel and contraceptive users as compared to the 2003 survey were observed in both the intervention villages (Antenatal immunizations: Nyaung Zauk: +56.4, Kyaouk Phoo:+44.0%, births attended by skilled health personnel (Nyaung Zauk: +19.3, Kyaouk Phoo: +18.6, and contraceptive users of modern methods: Nyaung Zauk: +24.6, Kyaouk Phoo: +18.4%) (data shows percentage increase in number of users). 2. Changes in the WVG members  A total of 74 people, including 22 WVG members, 8 people directly involved in the program, 19 WVG’s family members, and 23 villagers, were interviewed. As a result of analysis of WVG changes, 28 subcategories and 10 categories were extracted. WVG members developed from a stage of ignorance to a stage of ‘extension of consciousness derived from acquirement of knowledge’, with the core of ‘behavior changes caused by acquirement of knowledge that can be used in daily life’ participation in WVG program being the trigger for this change. In the process of change, it has reasonably set forward by ’function application of village societies’. ‘Family supports’, ‘handling of money’, and ‘the presence of medicines’, had direct effects on the process of these changes. These changes were attained due to ‘the women’s motivation to participate’ and ‘their Buddhist cultural background’. Furthermore, ‘the sense of gratitude projected by the local community’ and ‘the collaboration with the basic health staff’, in the form of greater cooperation, appeared as secondary benefits of the program. 3. Satisfaction with the WVG’s activities A total of 33 people, including 8 people directly involved in the program and 25 people from the community, were interviewed. The participants recognized 11 items of WVG services in all. Over half of the participants recognized 3 items involving loans for the funds for family planning, first-aid of wounded people, and health education in both villages of Nyaung Zauk and Kyaouk Phoo as important WVG services. Analysis of opinions about WVG activities led to one category of ‘appreciation of voluntary services’ being extracted. In terms of analysis of WVG issues, two categories of ‘handling of drugs’ and ‘request for activities for fund generation’ were extracted. Future expectations of the WVG included ‘repletion of drugs’, ‘maintenance of activities’, ‘extension of more activities’, and ‘no money, no healthy life’. IV. Discussion 1. Success of the program As a result of this program, an increase in knowledge and a growth of awareness were more eminently seen in the intervention villages where the Development Program for WVG was introduced, especially with respect to issues such as abnormal symptoms during the perinatal period, contraception, first aid for injuries, and environmental hygiene and sanitation. Now, four years after development of the WVG program was first started, it is obvious that instructions given during the early stages of the program have been put into practice and are being applied as effective knowledge. Although improvements in the number of antenatal immunizations, births attended by skilled health personnel and contraceptive users have occurred in the intervention villages as compared to the baseline survey of 2003, there are still significant differences as compared to the specified control village (village “I”), where they have reliable midwives who reside in the community and are willing to provide consultations to pregnant women and are also willing to accept delays in payment. Based on the results of this study, 2 suggestions can be proposed for improvement of the reproductive and child health environment in the rural areas of developing countries. First, inhabitants in the same community should, either publicly or privately, exchange information and simple aids between themselves, as needed, so that the knowledge and awareness of all people increases and is maintained. Women’s acquisition of capabilities leads to empowerment and activation of the community itself. Establishment of a system utilizing of health volunteers leads to long-term improvement in the health environment of the entire community. Secondly, this program also demonstrates that good quality care—“good quality” here implying adequate education, easy accessibility and dependability for the people of a community—is indispensable to the improvement of reproductive and child health. One of the targets of the Millennium Development Goals, namely ‘reduction by three quarters of the maternal mortality ratio,” includes the criterion of ‘the proportion of births attended by skilled health personnel’. As the shortage of health personnel is seriously worsening in developing countries, it is difficult to improve these indicators unless there are professionals who do not merely physically exist but who practice with guaranteed quality. Drawing up a “tailor-made” design to fit the available resources and the people’s needs, within the limits of local economic and human resources, will eventually pave the way for improvement of the reproductive and child health of communities in developing countries. 2. Changes in the WVG members The changes that took place in the group has its roots on the mental growth of each individual member of the WVG. The first words heard of everyone were “I’ve got knowledge,” as the women had instruction they had never had before. WVG members had obtained their knowledge of health that had then been consolidated through repetition via dialogues with others. Thereafter, the extension of consciousness, either through development of personalities or improvement of human relationships in the local community, appeared through transmission of the obtained knowledge. Many of the WVG members have achieved extension of consciousness derived from acquirement of knowledge, heightened by behavior changes brought about by acquirement of knowledge that can be practices in daily life, resulting from supporting the health of the community people by sharing their knowledge with other people involved in the program, as well as with outsiders. 3. Future direction of the Program   Analysis of the level of satisfaction with the WVG's activities highlighted the fact that expanding the role of the WVG to include supply of medicines to the community would positively affect the sustainability of the program. V. Conclusion The WVG Program for the improvement of reproductive and child health at the community level was evaluated in Myanmar. The system of development of women as “lay experts” in the community has been continuing since the program was first put into practice 4 years ago. The program has resulted in favorable changes such as improvement in the knowledge of perinatal care, contraception, first-aid and hygiene consciousness among the community. The program also resulted in changes in the WVG members themselves in terms of extension of consciousness derived from acquirement of knowledge together with behavior changes caused by the acquirement of knowledge applicable to daily life, occurring as a direct result of participation in the WVG program. In future, it is suggested that the role of the WVG be expanded to include supply of basic medicines to the community in order to positively affect the sustainability of the program.
Description: 聖路加看護大学大学院看護学研究科博士後期課程博士論文
Degree field : 博士(看護学)
URI: http://hdl.handle.net/10285/1390
Appears in Collections:2-3-b:博士論文(要旨あり)

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