Research on some related factors to Dao women health care services in socio-Cultural aspects in Bach Thong district, Bac Kan province

1 BACKGROUND Health of women and children are the top concerns of countries around the world including Vietnam. In Vietnam, women health care have remarkablly achieved results, many indicators related to reproductive health care has reached and exceeded objectives. However, economic, cultural, social development in mountainous areas are still much lower than other areas affected to the healthcare services for people. Besides factors such as low educational level, low living standards, traffic difficulties there are cultural elements such as backward customs, worship the Ghost when sickness that would affect health services utilization and approach, especially ethnic minorities including Dao ethnic. Therefore, analyzing the impact of cultural and social factors to health services of Dao in general and of Dao women in particular are necessary to contribute solutions in protection and health care for ethnic minority women. In Vietnam, many related rerearchs have been conducted. However, systematic researches concerning health services for Dao people in general and for Dao women in particular on socio-cultural aspects have not been carried out. Due to reasons above, we choose Bac Kan province (province has large number of Dao ethnic that only behind Tay ethnic) to research topic: "Research on some related factors to Dao women health care services in socio-cultural aspects in Bach Thong district, Bac Kan province" Study objectives 1. To describe and analyze the needs, supply and utilization status of health care services to Dao women on cultural, ethnic and social aspects in some communes in Bach Thong district, Bac Kan province. 2. To analyze some related factors concering to supply and utilization for the existing mother health care services in local areas. 2 NEW CONTRIBUTIONS OF THESIS 1. The first research in Viet Nam studied systematicly and depthly analyzied about some socio-cultural aspects relating to the supply and utilization of reproductive health care services of Dao women. 2. The first time using the combination of classic research Methods, Qualitative Research (PRA) and evaluation methods based on five indicators by chart CBM logic, along with samples of cases tracked consecutive 12 months to identify the factors related to health care Dao woman, as prerequisite for strengthening the activities of health services for Dao women on some cultural – society aspects. . IMPLICATION OF THE THESIS 1. Identified the needs, supply and utilization status of Dao women health care services. A base from which the proposed activities strengthen health services in the province. 2. Analyzed the factors related to supply and use health services of Dao women. Among them, cultural - society factors have much influence to women health. Local activities to enhance health services reached some initial results based on the identification of factors related above, a base for operations orientation strengthening health services for Dao ethnic in particular and for ethnic minorities in general. LAYOUT OF THE THESIS Thesis includes 105 pages. Introduction 02 pages Chapter 1: Literature review 23 pages Chapter 2: Methodology 14 pages Chapter 3: Results of the study 40 pages Chapter 4: Discussion 23 pages Conclusions and recommendations 03 pages 107 deferences were used in the thesis (84 in Vietnamese, 23 in English), 37 tables, 7 graphs, 29 photos, 4 pictrures. 3 Chapter 1 OVERVIEW OF DOCUMENTS 1.1. Cultural definition Culture is a broad concept with many connotations different interpretation, involving all aspects of material life and the human spirit. In 2002, UNESCO has offered this definition of culture: "Culture should be addressed as a set of characteristics in mind, physical, and emotional knowledge of a society or group in society and it contains, in addition to the literature and the arts, both living and modes of living together, value systems, traditions and beliefs ". In summary, organic cultural attachment to people, we can understand an aspect of culture that is the custom, customs, habits, lifestyles of the people are formed, survive and development of human life. The elements of culture include nine basic content: language, food, accommodation, clothing, beliefs, rituals, folk art, folk knowledge and the different traditions (funeral, marriage, the new house, healing, family...). 1. 2. Some culture charecteristics of Dao ethnic related to the health 1.2.1. Language Voice of the Mongolian - Daolanguage group, the number of people fluent in the language of literature is not much. Due to the nature of language, in the process of communicating health officials face many difficulties because of language barrier. 1.2.2. Housing Houses of the Dao is mainly a ground. House has a low roof, small windows, always low humidity, lack of air and low light. The vast majority of households do not use the bathroom and toilet. 1.2.3. Eating, drinking After delivery, women having a personal food, food is mainly meat, pork and chicken are cooked with herb drugs. Dao people drink tea and some leaves have an aromatic cool, easy to drink and used to treat diseases. More common type of drinking is alcohol made from yeast leaves. 1.2.4. The practice of reproductive and take care children In the past, when women who have children often have to delivery themself, umbilical cord is cut with sharp bamboo. In recent years, the birth of the Dao have been many changes, obstetric complications, mortality in infants ... have been minimized, Dao population increased significantly. 4 1.2.5. Beliefs related to illness The Dao people concept that when the spirt is full in the human body that mean they are very well. If the spirit in any position is absence, it will cause sickness. To avoid negative consequences, it must invite the sorcerer to call spirit or ransom to come back. 1.2.6. Customs and habits: Worship the Ghost, delivery at home has been remained. 1.2.7. Some intolerance: When pregnant, women diet of hard working, a couple living diet, diet food rancid. During pregnancy they do not talk out, diet in eating so it is easy to decline their health, affecting the development of the fetus. 1.2.8. Knowledge in folk medicine: Dao people know to process alot of type of traditional medicine, such as cooking drugs, alcohol drugs, pure drug, broken bone drugs ... Among them, the outstanding was bath drug for women postpartum, it helped women to recover health quickly, it was accepted by the community. 1.3. Health situation, reproductive health of women Incidence of diseases in women are generally higher than men, overall rates of 2.5 disease / person, women with diseases of the reproductive system, urology higher than three times men. 1.4. Women in access and use of health services Approaching health service depends on four basic groups of factors: distance from home to medical facilities, economy, health care, culture - society. The relationship between access and use health care: If the "supplier" lack the necessary resources, will lead to efficient resource utilization is low. If the "demand" does not demand the right, not to accept, do not use the health which the "supplier" ready to offer, this leads to waste of resources and effective community health care services is limited. 1.5. Management system of primary health care - assessment tools to approach and use of health services CBM - Community Based Monitoring - a method of assessing access and use of health services. The main goal of CBM is to determine health care needs have been met or not, how to meet, the cause of obstructing the use of health services and the existence of the health services provider through indicators: availability, approach, using, use enough and use effectively. 5 Chapter 2 OBJECTS AND METHODS OF STUDY 2.1. Objects, places and time study - Married Dao women from 15 to 49 years old in Don Phong and Duong Phong commune, Bach Thong district, Bac Kan province. - Research time: 2 years, from 01/2008 to 12/2009 2.2. Research methodology - Research description: cross-sectional survey combines quantitative, qualitative (PRA) and track 12 months was conducted on the whole number of married Dao women from 15 – 49 years old to describe specific of ethnic Dao and some specific cultural - social; reality provides and uses health care. - Research analysis: Evaluating the health care through five logic indicators (availability, access, use, enough use, efficient use), paper cases (with check list) to discover trends range of services, the problem exists, assessing the quality of health service. - Sample size and choosing a sample: Select the form intent. The sample size includes all married Dao women who are 15 to 49 years old, including 329 women, in which 80 women with children under 5 years old and / or are pregnant. 2.3. Research technique -The variables of population, demographic, housing, water source, distance from home to medical station; medical personnel, facilities, medicines and equipment were recorded by survey techniques (surveys 329 married Dao woman from 15 - 49 years old; 60 health staffs who are working in 17 medical stations belong to Bach Thong district), observed (photos). -The variables of characteristics cultural - society relating to health of Dao woman are collected by using PRA techniques: mapping (2), ranking (1); life story (1), seasoning(1), matrix (1), in-depth interviews (5), discussion groups (3). -The variables of knowledge, skills of its medical staff are evaluated through the methods of paper case combining the check list. 6 - The variable about tend to health services (5 indicators logic) are evaluated by CBM chart and track 12 consecutive months. 2.4. Evaluation criteria about indicators research Index performance evaluation of active primary care: The evaluation criteria recognized by national standard for commune health. Index performance evaluation of reproductive health care for the period 2001 - 2010: folowing The decision of No 136/2000/QD - TT of the Prime Minister on 28th November 2000. Index performance evaluation the knowledge of health staff on reproductive health: excelent = 9 - 10 points; good = 7 - 8 points; average = 5 - 6 points, bad = 1 - 4 points, a basic error = 0 points Five logical indicators: According to the formula prescribed by the Ministry of Health, including: * Monitor the health care of pregnant women before delivery: + The rate of available: (number of days reporting period - Number of days unavailable) x 100 / number of days reporting period). The number of days unavailable in iron, albumin urine test paper (or solution to test), antenatal care and blood pressure check during the next report from the monitoring book. The number of days not available are the total number of days without one or more of the things mentioned above. + The rate of approaching: (the access number x 100) / Total population. People approach the total population live in villages where time travel to the clinic by conventional means available shall not exceed one hour and each month receive health care of pregnant women at foreign stations at least once time if more than an hour away. + The rate of utilization: (number of women have prenatal care x 100) / estimated number of women giving birth. As the proportion of pregnant women were examined at least 1 time before birth during the reporting period. + The rate of full utilization: (number of antenatal care enough x 100) / estimated number of women giving birth. As the proportion of pregnant women for antenatal care at least 3 times before they give birth during the reporting period. + The rate of effective utilization: (number of well-maintained x 100) / estimated number of women giving birth. Number of good care is the number of prenatal care are three times at three gestation, were vaccinated against tetanus two times and received the iron before birth during the reporting period. 7 * Monitor the health care of women during and after birth: + The rate of available: Following the above formula. The dates of oxytocin is unavailable, sterilize instruments, delivered tools during the reporting period from the monitor book. + The rate of access: Folloing the formula above. + The rate of utilization: (number of women delivered by medical staffs x 100) / number of women giving birth (estimated). If having exactly number of delivered women, not the estimated number of women giving birth. + The rate of full utilization: (The care enough x 100) / estimated number of women giving birth. Number of care enough are the number of women who have at least 3 times antenatal care, giving birth by health care staffs and received postnatal care (at least 2 times within 42 days after birth). + The rate of effective utilization: (number of well-care x 100) / estimated number of women giving birth. Number of good care is the number of women who have at least 3 times examination in 3 periods of pregnancy, giving birth by health care staffs, received postnatal care (at least 2 times within 42 days after birth) and give birth in medical station with the support of the means of delivered (the clean package delivered and the set of delivered tools) during the reporting period. * How to read CBM charts The vertical axis indicates the rate of the factors related to health issues. The horizontal axis indicates the factors that are related closely. Diagram is drawn when the results of the target factors, the availability, access, use, full utilization and effective utilization has been made in tracking together. If the path of the chart tend to decline that means have some problems in public health care and this matters should be resolved. More and more declining level that means have more and more health care problems in community and priority needs to be resolved. Level of decline of the chart decreases means that activity medical progress. 2.5. Data processing method Research data is processed and analyzed by using statistical software SPSS. The qualitative research data are presented as methods for qualitative and complement the results of quantitative research. 8 Chapter 3 RESULTS OF STUDY 3.1. Some cultural - social charateristics of the Dao people in Bach Thong district, Bac Kan province Table 3.2. Characteristics of married Dao women aged 15 to 49 in two research communes in 2009 Characteristics of Dao women Number (n = 329) % Education level Illiteracy 65 19.8 Can read and write 53 16.1 Primary school 126 38.3 Secondary school 68 20.7 Hight school 16 4.9 Colleges, universities 1 0.3 Dao women's career Farming, upland 321 97.6 Civil servants 2 0.6 Other 6 1.8 Comments: Education of Dao women are very low, occupation mainly is in farming. Table 3.4. Characteristics of house, water source and stable of Dao people in two research communes Housing, water source, stable Number (n = 329) % Type of accommodation Strongly built house 6 1.8 Semi-permanent 124 37.7 Provisional 199 60.5 Water source Stream water 178 54.1 Rainwater 54 16.41 Wellwater 19 5.78 Carrying water 78 23.71 Barn From house ≤ 10 m 198 60.18 From house > 10m 131 39.82 9 Comments: House is mainly a temporary (60.5%). Stream water is mainly water source of the Dao (54.1%). Most of barns near the house so that it is very unhygienic. Table 3.6. Characteristics of distance, time and vehicles to the nearest health facility Variable Number (n = 329) % Distance from home to CHCs ≤ 5 km 94 28.6 From 6 to 10 km 197 59.9 From 10 km or more 38 11.6 Min = 2 Max = 30 Mean = 7.84 The time from home to CHC by ussually used vehicles Under 60 minutes 78 23.71 More than 60 minutes 251 76.29 Vehicles Walk 76 23.1 Bicycles 45 13.7 Motorcycles 197 59.9 Other 11 3.3 Comments: Having 76.29% of households take more than an hour to the nearest CHCs by ussually used vehicles. * The result of depth interviews, life story to understand the concept of Dao people in health, disease, customs that related to childbirth, Mr. Ban Van K (Priest), Ms. Ban Thi K (village leader) , Ms. Trieu Thi H said that: Dao people concept that disease was made by Ghost so that they attach much important to worship. When sicknes, they both worship at home and go to the health care. When Dao women giving birth, they are cared carefully with traditional herbs, typically is bathherb for women after giving birth. The habit of Dao people is to reserve medicine at home. When sickness, they take the traditional medicine theirself or self-purchase model medicine. If their health are not better, they go to medical facilities later. 10 3.2. Supply status of health services at basic health system Table 3.7. Human resource of 17 CHCs in Bach Thong district in 2009 Human resource Number % Total of health staffs of 17 medical stations 65 100 The rate of commune with doctor 8 47.05 The rate of commune with midwifery 10 58.82 Graduate Medical Polyclinic 19 29.23 Nursing 23 35.38 Druggist 1 1.54 Herbalist 4 6.15 Medical man / total villages 148/148 100 Collaborater of population / total villages 94/148 63.51 Health staff/1000 people (65/5657) 1.15 Midwifery / women aged 15-49 (10/1659) 0.6 Average of health staff / CHC 3.82 Comments: The rate of doctors in CHCs is still low (47.05%), midwives are about 58.82%. Table 3.9. Infrastructure, drugs and equipment at 17 CHCs in 2009 Sufficient Insufficient No have Index n % n % n % 1. Facilities Health station 17 100 Function rooms 4 23.53 13 76.47 Water source 6 35.29 8 47.06 3 17.65 Kitchen 7 41.18 10 58.82 Sanitary toilet 4 23.53 13 76.47 Electric 4 23.53 13 76.47 2. Basic equipment Blood pressure 16 94.12 1 5.88 Thermograph 16 94.12 1 5.88 Stethoscope 17 100 3. Required equipment Set of dental 7 41.18 2 11.76 8 47.06 Set of ENT 4 23.53 13 76.47 Set of ophthalmology 2 11.76 15 88.24 11 Sufficient Insufficient No have Index n % n % n % 4. Drugs Number 9 52.9 8 47.1 Kind of drugs 15 88.2 2 11.8 Pharmacy 3 17.6 14 82.4 Comments: Most CHCs lack functional departments and requred instruments. About 47,06% CHCs have no dental instruments; 76,47% without ENT instruments; no eye examination instruments (88,24%). Not enought sufficient drugs (47,1%). About 82,4% have no pharmacy. Table 3.10. Obstetric equipments at 17 CHCs in Bach Thong district in 2009 Sufficient Insufficient No have Index n % n % n % 1.Facilities, instruments O & G department 4 23.53 10 58.82 3 17.65 Gynecology table 10 58.82 4 23.53 3 17.65 Tools of antenatal 7 41.18 10 58.82 0 Tools of delivered 8 47.06 6 35.29 3 17.65 Tools of family planning 7 41.18 6 35.29 4 23.53 Scale for new born 15 88.24 0 2 11.76 Scale for adults 13 76.47 0 4 23.53 2. Drugs Oxytoxin 11 64.71 3 17.65 3 17.65 Ion 5 29.41 9 52.94 3 17.65 3. Other equipments Antenatal sheets 5 29.41 12 70.59 0 Albumin paper test 0 17 100 0 Wire size 17 100 Comments: Most of CHCs lack O&G treament rooms. About 17.65 % stations do not have any tool to use; 23.53% stations do not have family planning tools; 17.65% have no oxytocin and iron. The rate of stations lack iron is 52.94%. About 70.59% missing sheets for antenatal care and 100% do not test albumin urine. 12 Table 3.11. Knowledge of CHC’s staffs on reproductive health care (n = 60) Doctors Midwives Nurses Total Ranking n % n % n % n % Excellent 0 0 0 0 Good 8 13.33 4 6.67 5 8.33 17 28.33 Average 16 26.67 6 10 12 20 43 56.67 Not good 3 5 0 6 10 9 15 Total 27 10 23 60 100 Comment: Knowledge of health staffs about obstetric care is still limitted, have no scored well, bad on knowledge is 15%. Table 3.12. Antenatal care skills of health workers (n = 60) Ranking Doctors Midwives Nurses Total n % n % n % n % Excellent 0 0 0 0 Good 7 11.67 4 6.67 4 6.67 15 25 Average 13 21.67 4 6.67 11 18.33 28 46.67 Not good 7 11.67 2 3.33 8 13.33 17 28.33 Total 27 10 23 60 100 Comment: Skills of health staffs about antenatal care are very weak, have no good ratings. The rate of not good practice are very high (28.33%). 3.3. Disease patterns, healthcare needs and how to treat when sick Table 3.13. Situation of sickness of Dao’families in the two weeks before survey at two communes Variable Number (n = 329) % Have sickness 99 30.1 Sick members in family (n = 99) Wife 23 23.23 Husband 16 16.16 Children 38 38.38 Other 22 22.22 13 Comment: In two-weeks preceding the survey, nearly one-third of households have sickness (30.1%), sickpersons were mostly children (38.38%) and women (23.23 %). Table 3.14. Number visits to CHCs at two research communes in 2009 Dao ethnic (n = 1676) Other ethnic (n = 3657) Total (n = 5.333) Diseases group SL % SL % SL % p Respiratory 710 42.36 1608 43.97 2318 43.47 Digest 71 4.24 183 5.00 254 4.76 Cardiovascular 52 3.1 105 2.87 157 2.94 Urology 26 1.55 67 1.83 93 1.74 >0.05 Gynaecology 292 17.42 372 10.17 664 12.45 Musculo, bone 124 7.4 430 11.76 554 10.39 <0.05 Injury 27 1.61 66 1.80 93 1.74 Eyes 33 1.97 53 1.45 86 1.61 Dental 309 18.44 701 19.17 1010 18.94 Dermatology 24 1.43 41 1.12 65 1.22 Other 8 0.48 31 0.85 39 0.73 >0.05 Total 1.676 100 3.657 100 5.333 100 Comment: Respiratory infections accounted for the highest percentage (43.47%). The rate of gynecological diseases of the Dao women (17.42%) is higher than the other ethnic (10.17%) with p <0.05. For other diseases, there are no significant difference (p>0.05). Table 3.17. Use of prenatal care of Dao women in two research communes in 2009 Variable Number (n = 80) % Number of antenatal visits No prenatal visit 18 22.5 Only one time before birth 59 73.75 Only two times before birth 2 2.5 At least three times before birth 19 23.75 Number of using tetanus vaccine Do not inject any time 7 8.8 One time 30 37.5 ≥ 2 times 43 53.8 14 Comment: The majority (73.75%) of Dao women have only one time visit CHCs for antenatal care. The rate of pregnant women who examined from three or more times are lower (23.75%). Table 3.18. Use during and postnatal care of Dao women at two research communes in 2009 Variable Number (n = 80) % Place of birth Community health center 13 16.25 Hospital 51 63.75 At home with medical support 10 12.5 At home without medical support 6 7.5 Place of treatmen when women have abnormal after giving birth Self-treatment 14 17.5 Community health center 18 22.5 Hospital 5 6.25 Not be examined within 42 days after geving birth 73 91.25 Comment: About 20% of women give birth at home, in which 7.5% delivery at home without medical staff. Delivering at CHCs accounted for the low rate (16.25%), even lower than delivery at home (20%). Most women (91.25%) are not examinated within 42 days after giving birth . Table 3.19. Comment of the Dao women about the activities of community health centers (n = 329) Satisfied Unsatisfied Health's activities n % n % Wait examination 249 75.7 80 24.3 Medical procedures 208 63.2 121 36.8 Qualification 169 51.4 160 48.6 Drugs 53 16.1 276 83.9 The attitude of physicians 134 40.73 195 59.27 Price 248 75.4 81 24.6 Equipment 62 18.8 267 81.2 Open hour 285 86.6 44 13.4 Comment: Most of Dao women are not satisfied with drug supply (83.9%); equipment (81.2%). About 59.27% of women who are unhappy with physician attitude; professional quality (48.6%). 15 Table 3.21. Initial treatment of Dao woman when sickness in two weeks before survey The way of treatments Number (n = 99) % Do not use anything (or spell) 37 37.37 Self treated with herb 29 29.29 Self-purchase medicine 13 13.13 To the health-care 9 9.09 Worshiping at home 7 7.07 Private Clinics 0 0 Other 4 4.04 Comments: When they had sickness, they did not use any thing or just spelled at home (37.37%), self-treated with herb (29.29%), self- purchase medicine (13.13%), to the health care (9.09%); only worship at home (7.07%). Table 3.22. The reason for not going to health facilties of sick Dao within 2 weeks before conducting a survey Reasons for not seek medical Number (n = 99) % Mild disease 72 72.73 Not enough money 69 69.7 Health facilities too far 53 53.54 The attitude of doctors is not good 50 50.51 Do not believe the doctor 37 37.37 Many times to treat patient but not well. 19 19.19 No time (Busy season) 11 11.11 Incurable disease 3 3.03 Other 15 15.15 Comment: They do not seek medical care because of mild disease (72.73%), not enough money (69.7%); health facilities too far (53.54%); 50.51% by physician's attitude is not good and 37.37% do not believe the doctor. The reaseons such as no time or busy season occupies 11.11%. 16 3.4. Utilization status of health services of Dao women Table 3.25. The coverage of health care services for pregnant women before giving birth from 2007 to 2009 in two research communes Percentage 2007 2008 2009 Available 72 85 94 Approachable 61 65.5 76.04 Utilization 39.34 70 73.75 Full utilization 21.31 24.28 23.75 Efficient utlization 14.75 17.14 17.94 14,7521,31 39,34 61 72 17,9423,75 73,75 76,04 94 100 0 20 40 60 80 100 120 Target Available Approachable Utilization Full utilization Efficient utilization 2007 2008 2009 Chart 3.1. Coverage of health care services chart for pregnant women before giving birth from 2007 to 2009 in two research communes Comment: Health care service for pregnant before giving birth are still remaining 5 stages from inputs to outputs. In which, the biggest trouble is full utilization. There is great disparity between the number and quality of service. The coverage of the service tends to increase, especially the utilization rate. Table 3.27. The coverage of health care services for pregnant women during and after giving birth from 2007 to 2009 in two research communes Percentage 2007 2008 2009 Available 84.36 100 100 Approachable 61.27 65.5 76.04 Utilization 48.34 50.1 62.3 Full utilization 9.83 10.42 11.53 Efficient utlization 0 5.65 8.2 17 0 9,83 48,34 61,27 84,36 8,2 11,53 62,3 76,04 100100 0 20 40 60 80 100 120 Target Available Approachable Utilization Full utilization Efficient utilization 2007 2008 2009 Chart 3.3. Coverage of health care services chart for pregnant women during and after giving birth from 2007 to 2009 in two research communes Comments: The coverage of the service tends to increase over the years, the biggest problem is full utilization. Table 3.31. Health services utilization for Dao pregnant women during giving birth in two research communes 2007 2008 2009 Variable n % n % n % Number child alive/year 43 40 30 Delivery at CHCs 11 25.58 7 17.5 5 16.67 Delivery in the hospital 20 46.51 23 57.5 19 63.33 Home delivery with staff 8 18.6 7 17.5 4 13.33 Home delivery without staff 4 9.3 3 7.5 2 6.67 Comments:The rate of delivery in hospitals tend to increase. The percentage of children are delivered at CHCs and at home tends to decrease. However, at the present, children are delivered at home, especially without health staff. Table 3.33. The coverage of expand vaccination services for children from 2007 to 2009 in two research communes Ration 2007 2008 2009 Available 91 92.5 94.5 Approachable 72.6 79.82 76.04 Utilization 97.01 97.4 97.5 Full utilization 95.52 96.1 95 Efficient utlization 0 0 0 Comments: Expand vaccination services for children has been quite good, but the effective utilization rate is 0% due to the cold chain is not satisfactory and this rate has not improved in 3 years. 18 Table 3.34. Effectiveness of solutions in enhancing equipment, drugs and professional training in two research communes Variables 2008 (Before intervene) 2009 (After intervene) Equipment Dental seats 1/2 2/2 Adult dental care 0/2 2/2 Child dental care 1/2 2/2 Microscope 0/2 1/2 Training Dental Technician 0/2 2/2 Pap technique 0/5 5/5 Full drugs for cure gynecological 0/2 2/2 The fund's average for CHC (million / year) By people’s committee 3.9 4.25 By District Health Department 1.25 2.85 By District People's Committee 0 1.5 By self - CHCs 0.27 1.24 By the project, organization donors 3 12.2 Comment: Equipments, drugs and instruments have been equipped enought for CHCs. Health workers have been training. In particular, funds that made by CHCs were increased from 0.27 to 1.24 million VND. Table 3.35. The number of visits to CHCs at two research communes in 2009 Before intervention (6-first monthst) After intervention (6-last months) Number of visits to CHCs n % n % P value Dao ethnic Total visits 703 41.95 973 58.05 Gynecological 58 19.85 234 80.15 Periodontal disease 55 17.8 254 82.2 <0.01 Other ethnic Total visits 1838 50.26 1819 49.74 >0.05 Gynecological 79 21.23 293 78.77 <0.01 Periodontal disease 133 18.98 568 81.02 <0.01 Comments: Total medical gynecological and dental diseases of the Dao and other ethnic groups increased significantly (p <0,01). Total examination of the Dao increased from 41.95% to 58.05% (p <0,01). 19 Chapter 4 DISCUSSION 4.1. Some cultural - social characteristics of Dao people related to health - Housing: mainly temporary account for 60.5% (Table 3.4), barn near the house. Perhap, due to housing is unhealthy so that percentage of sick children in two weeks preceding the survey was 38.38% (Table 3.13) and the rate of respiratory infection was 42.36% (Table 3.14). - The water source: used was mostly stream water, carryingwater. Most families have no bathroom. Perhaps, because of the water source is not guarantee so gynecological rate in Dao women higher than other ethnic (17.4% versus 10.1%) (Table 3.14). - Traffics: About 76.29% of households take more than an hour to get to CHCs (Table 3.6). Distances so far is one of the reasons for the 53.54% who did not seek medical (Table 3.22). This result is consistent with the findings of the Health Ministry's investigation. - Herb bath and reproductive habits: Bath with medicinal herbs after giving birth of Dao women is a specific culture of the Dao. All postpartum women who Dao bath with Vietnamese traditional medicine (Table 3.30) to quickly recover their health. Herb - bath is one of a good custom need to promote this custom. However, up to now Dao women have still given birth at home (20%), although the tends of giving birth at home is decreasing. It is noted that birth rate in medical station also tend to decrease (Table 3.18), the cause is due to reproductive health services at the station does not meet the demand, lack of obstetric and gynecology department, lack of medicine, weak professional ... make Dao people do not believe in medical staffs and station (Table 3.19, Table 3.22). Because of ethnic beliefs, so Dao women who are pregnant and when the birth are great abstinence, especially not for strangers to come in their home and they themselves do not go outside. Perhaps this is one of the reasons make 91.25% of Dao women are not examined after birth? (Table 3.18). Dao women avoid hard working, rancid food during pregnancy and childbirth. They are cared carefully by the family in order to have enough breastfeeding... These are good abstinence for healthy, so health staff should communicate widely to members of the family to take care pregnant women during and after birth well, helping to reduce the rate of fetal malnutrition, improving race . 20 - Beliefs related diseases: Dao people concept that disease is caused by Ghost, so when they have sickness they spell and witchcraft firstly, it occupied the highest rate of 37.37%; worshiping in home was 7.07% (Table 3.21), with mild disease they witchcraft or using oil lamp, if it was not better then they used Vietnamese traditional herb or buy drugs, with a serious sickness, they also has taken to the health station and worship at home at the same time (Matrix). Belief in worshiping Ghost (Spirit) when sickness also helps sick people have confidence in mysterious power, but if they only believe in worshiping and not go to medical facilities it may be dangerous to life. Therefore, we need to widely communicate for Dao people to the medical facilities when sick on time. 4.2. Health care needs, supply status and utilization of health services for Dao women 4.2.1. Health care needs Percentage of sick Dao people for 2 weeks before the survey was 30.1%. The rate of sick Dao women was 23.23% this was lower than sick children (38.38%). The rate of Dao women with gynecological was 17.42% higher than women of other ethnic groups (p <0.05). 4.2.2. Supply status and utilization of health services for Dao women 4.2.2.1. The human resource, facilities, medical equipment in general and reproductive health care in particular - Human resources: The rate of doctors was low (47,05%), rate of midwives was 58.82% (Table 3.7). Lack of doctors and midwives causes quality and safety of services. Qualification of health staffs about obstetric care is still limited (Table 3.11 and 3.12). This leads 48.6% Dao peope are unhappy about professionals (Table 3.19); 37.37% Dao people disbelieve health staffs and it is the reason that they do not go to CHCs for examination (Table 3.22). As well as the reproductive health service is not good so that Dao peope tend choosing hospitals instead of CHCs in giving birth (Table 3.31). - About facilities: Most of the CHCs lack O&G rooms. About 7.65% of CHC have no type of this department (Table 3.10). - About obstetric equipment : More than 1/3 the number of CHCs do not have enough deliver tools and family planning tools (Table 3.10). A lack of obstetric equipment has prevented medical staff doing health service at medical well. 21 - About drugs: About 47.1% of CHCs did not have enough drugs to allocate; 82.4% of CHCs have no pharmacy; 17.65% of CHCs have no oxytocin and iron. Percentage of stations lack of iron is 52.94%; 70.59% lack of ticket for antenatal care and 100% do not test albumin urine (Table 3.9 and 3.10). Lack of drugs is also the reason why health officials are not assured when the procedure and the mother is not assured to give birth at the station. As a result, lack of facilities, health stations, O & G department, lack of specialized instruments, lack of medicine, not high professional qualifications, training incoherent... were great difficulty to be able to deploy the work of health care for the woman. This has reduced the rate of utilization before, during and after the birth service (Table 3.25, Table 3.27). 4.2.2.2. The situation provides health care services for pregnant women before birth Health care services for pregnant women before birth has existed in five stages from inputs to outputs. In particular, the biggest problem is full utilization. However, services tend to increase (Table 3.25). 4.2.2.3. The situation provides health care services for pregnant women during and after birth The coverage this service tend to increase (Table 3.27), however, the rate of effective utilization is 0%. This indicates a problem to overcome here is to improve the quality of service. 4.3. Some factors affecting Dao women's health care services in the areas of research - Effects of some socio-cultural aspects: + Due to the high rate of the Dao poor (30.03%), low educational level (Table 3.1 and 3.2) therefor when they have sickness they do not used anything or only Cast spells and witchcraft at first, occupied the highest percentage 37.37% (Table 3.21). + Due to the concept that disease is caused by ghost so that if want to be treated well must worship the Ghost, Therefore, only 7.07% of Dao people worship at home, not going to the health facilities (Table 3.21). + Due to a number of backward customs and habits as delivery at home 20% (Table 18.3), 100% abstinence is not a stranger into pregnancy women (Table 30.3) has made effective utilization rate of the service postnatal health care was 0% (Table 3.28). 22 + Due to farming practices, busy season has made about 11,11% of Dao women does not have time to seek medical care (Table 3.22). + Difficult traffic, far away from medical stations are also factors that hinder Dao pepole from approaching to health service (Table 3.6). + Due to reside in the sacred forest, far from medical facilities so Dao pepole have experienced in using the forest trees as medicines, has 29.29% of Dao women who self-treated by traditional medicine so they do not go to health facilities (Table 3.21), 100% of Dao women use the herb bath after birth to recover their health more quickly. - Effect of the economic: In 2009, the rate of poor households in Bac Kan Province was 25.18% and the whole country was 11%. As a result, the rate of poor Dao households in Bach Thong district is still higher than the rate of poor households in Bac Kan province and country. Economic factors also influence the decision to use medical services of the Dao pepole. About 37.37% Dao people do not treat when they have sickness (Table 3.21); has 69.7% of Dao women who did not seek medical because they have not enough money, the money paid to borrow a share and loan lending accounted for 15.2% overall and 19.2% (Table 3.22 ). Our results match the results of the Ministry of Health. - Effect of providing health services: CHCs do not meet the health care needs of the Dao people. The status of missing drugs, lack of equipment, weak qualifications, chilly attitude, lack of medical information... was the reasons has made 83.9% of Dao people unhappy with drugs; 37.37% do not trust the physician (Table 22.3). 4.4. Assessment and analysis of factors related to supply and utilization of mother health care services available at the local By research methods in medical classic combines PRA methods helped provide local that measures to strengthen health care services for Dao women effectively: total examination of the Dao increased from 41. 95% to 58.05% is statistically significant (p <0.01). This expenditure by health stations increased from 0.27 to 1.24 million per year. 23 CONCLUSION 1. Health care needs, supply status and utilization of health care service of Dao woman in Bach Thong district, Bac Kan The needs of Dao health care is high requirement, illness rate is 30.1%, of which the needs of Dao women is 23.23% lower than the needs of child health care (38.38%). Dao women were gynecological (17.41%) higher than other ethnic women (10.17%) with p <0.05. Health care services for pregnant women before giving birth tend to rise, but uneven and still have many troubles. Existing from input to output, the biggest trouble is full utilization (23.75%). Health care services for pregnant women during and after birth rate achieved was 100% available, the ratio also tends to increase but not significantly. The biggest trouble is full utilization (11.53%). Child health care services have rather good results. 2. The factors that affect health care of Dao women - Some cultural factors: + Have not good influence on health care of Dao women: The concept of disease is due to make by Ghost, so worship was very common when they have illness, abstain from strangers entering their home after birth, busy season... to restrict women go to health care after birth (91.25% of Dao women are not examined after birth). Geographical distance, the terrain is also a factor obstructing Dao people to access health service (76.29% go to medical stations for 60 minutes or more). Still have 20% of Dao women delivered at home with medical or without medical help. + Have a good affecting on health care to Dao women: 100% of Dao woman use herb bath after birth to recover health quickly. They avoid to work hard when having pregnance, abstaining from eating stale. During pregnancy and childbirth period, they are taken care of family menbers with mental and material that help women recover quickly to breast feeding. - Some of the factors of economy, society and ethnic: the high rate of poor households Dao (30.03%), low education level, little receives health information led to poor awareness about the disease as well as how treatment when sickness are very difficulty: About 37.37% of sick Dao women did not use any drugs or just the Cast spells and witchcraft; self treated with a traditional medicine (29.29%); self buy the medicine (13.13%); to the health office (9.09%); only worship at home accounts for 7.07%; no one go to the private clinics. 24 - Some factors about health service supply (insufficience and poor quality): poor facilities, drugs and equipment, lack of required equipments for specialized departments and gynecology. Qualifications of health staffs are not high, there is no excellent point, not good in knowledge was 15%, practice was 28.33%. Dao people were unhappy about the activities at CHCs: 83.9% due to lack of drugs; 81.2% due to lack of medical equipment; poor attitude of physicians (59.27%); poor professional qualification (48.6%). Therefore, about 50.51% of Dao people did not seek medical facilities because of doctors’ attitude and 37.37% did not trust phycians. 3. A number of factors related to supply and utilization of mothers health care services available at local After providing the activities such as purchasing new and additional equipments (dental, gynecological), training health staffs (Dental Technician, Technical Pap diagnosis and treatment of gynecological diseases), patients were in charge of fee in some services, enhanced funding for clinics, mobilizing support from organizations and individuals, strengthening the CHC’s abilities in examination, treatment, and health education... have obtained some results: Number of visits for gynecologist and periodontal disease increased significantly. Gynecological visits of Dao woman increased from 19.85% to 80.15%, number of periodontal visits increased from 17.8% up 82.2%. Similarly to Dao people, The number of gynecological visits and periodontal disease of other ethnic groups also increased. The total number of clinic visits increased from 41.95% of Dao people to 58.05% (p <0.01). RECOMMENDATIONS - Continuing to strengthen and enhance the CHC: investing essential equipments used for comon disease examination and treatment, enhancing training health staffs. - Monitoring and supporting CHCs: Using the coverd chart, paper case, the checklist. - Coordinating other social organizations to strengthen health education. - Mobilizing the community participation in health care activities based on the ethnic-cultural traditional aspects.