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 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 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 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 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 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 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 Chapter 1: Literature review Chapter 2: Methodology Chapter 3: Results of the study Chapter 4: Discussion Conclusions and recommendations pages 02 23 14 40 23 03 pages pages pages pages pages 107 deferences were used in the thesis (84 in Vietnamese, 23 in English), 37 tables, graphs, 29 photos, pictrures 3 Chapter 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 ) 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 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 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, 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 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: 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 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 = - 10 points; good = - points; average = - points, bad = - points, a basic error = 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 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 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 times antenatal care, giving birth by health care staffs and received postnatal care (at least 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 times examination in periods of pregnancy, giving birth by health care staffs, received postnatal care (at least 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 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 Number Characteristics of Dao women % (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 0.3 Dao women's career Farming, upland 321 97.6 Civil servants 0.6 Other 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 Number Housing, water source, stable % (n = 329) Type of accommodation Strongly built house 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 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 Number Variable % (n = 329) Distance from home to CHCs ≤ km 94 28.6 From to 10 km 197 59.9 From 10 km or more 38 11.6 Min = 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 47.05 The rate of commune with midwifery 10 58.82 Graduate Medical Polyclinic 19 29.23 Nursing 23 35.38 Druggist 1.54 Herbalist 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 Index Facilities Health station Function rooms Water source Kitchen Sanitary toilet Electric Basic equipment Blood pressure Thermograph Stethoscope Required equipment Set of dental Set of ENT Set of ophthalmology Sufficient n % 17 4 100 23.53 35.29 41.18 23.53 23.53 16 16 17 94.12 94.12 100 41.18 Insufficient n % 13 76.47 47.06 13 No have n % 76.47 11.76 23.53 11.76 17.65 58.82 76.47 1 10 13 5.88 5.88 13 15 47.06 76.47 88.24 11 Index Drugs Number Kind of drugs Pharmacy Sufficient n % 15 52.9 88.2 17.6 Insufficient n % No have n % 47.1 11.8 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 Index 1.Facilities, instruments O & G department Gynecology table Tools of antenatal Tools of delivered Tools of family planning Scale for new born Scale for adults Drugs Oxytoxin Ion Other equipments Antenatal sheets Albumin paper test Wire size Sufficient n % Insufficient n % No have n % 10 15 13 23.53 58.82 41.18 47.06 41.18 88.24 76.47 10 10 6 0 58.82 23.53 58.82 35.29 35.29 3 4 17.65 17.65 11 64.71 29.41 17.65 52.94 3 17.65 17.65 17 29.41 12 17 70.59 100 0 17.65 23.53 11.76 23.53 100 Comments: Most of CHCs lack O&G treament rooms About 17.65 % stations not have any tool to use; 23.53% stations 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% 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 Good 13.33 6.67 8.33 17 28.33 Average 16 26.67 10 12 20 43 56.67 Not good 10 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 Good 11.67 6.67 6.67 15 25 Average 13 21.67 6.67 11 18.33 28 46.67 Not good 11.67 3.33 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 Number Variable % (n = 329) 99 30.1 Have sickness 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 Diseases group Respiratory Digest Cardiovascular Urology Gynaecology Musculo, bone Injury Eyes Dental Dermatology Other Total Dao ethnic (n = 1676) SL % 710 42.36 71 4.24 52 3.1 26 1.55 292 17.42 124 7.4 27 1.61 33 1.97 309 18.44 24 1.43 0.48 1.676 100 Other ethnic (n = 3657) SL % 1608 43.97 183 5.00 105 2.87 67 1.83 372 10.17 430 11.76 66 1.80 53 1.45 701 19.17 41 1.12 31 0.85 3.657 100 Total p (n = 5.333) SL % 2318 43.47 254 4.76 >0.05 157 2.94 93 1.74 664 12.45 0.05 65 1.22 39 0.73 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) Table 3.17 Use of prenatal care of Dao women in two research communes in 2009 Variable Number of antenatal visits No prenatal visit Only one time before birth Only two times before birth At least three times before birth Number of using tetanus vaccine Do not inject any time One time ≥ times Number (n = 80) % 18 59 19 22.5 73.75 2.5 23.75 30 43 8.8 37.5 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 7.5 Place of treatmen when women have abnormal after giving birth Self-treatment 14 17.5 Community health center 18 22.5 Hospital 6.25 73 91.25 Not be examined within 42 days after geving birth 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 Do not use anything (or spell) Number (n = 99) 37 % 37.37 29 29.29 Self treated with herb 13 13.13 Self-purchase medicine 9.09 To the health-care 7.07 Worshiping at home 0 Private Clinics 4.04 Other Comments: When they had sickness, they did not use any thing or just spelled at home (37.37%), self-treated with herb (29.29%), selfpurchase 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 weeks before conducting a survey 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 3.03 Other 15 15.15 Comment: They 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% not believe the doctor The reaseons such as no time or busy season occupies 11.11% Reasons for not seek medical 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 17.94 120 2007 100 94 100 2008 76,04 2009 73,75 80 72 60 61 40 23,75 39,34 17,94 20 21,31 14,75 Target Available Approachable Utilization Full utilization Efficient utilization 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 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 Available Approachable Utilization Full utilization Efficient utlization 2007 84.36 61.27 48.34 9.83 2008 100 65.5 50.1 10.42 5.65 2009 100 76.04 62.3 11.53 8.2 17 120 100 2007 100 2008 100 76,04 2009 80 84,36 62,3 60 61,27 48,34 40 11,53 20 8,2 9,83 Target Available Approachable Utilization Full utilization Efficient utilization 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 Variable 2007 2008 2009 n % n % n % Number child alive/year 43 40 30 Delivery at CHCs 11 25.58 17.5 16.67 Delivery in the hospital 20 46.51 23 57.5 19 63.33 Home delivery with staff 18.6 17.5 13.33 Home delivery without staff 9.3 7.5 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 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 years 18 Table 3.34 Effectiveness of solutions in enhancing equipment, drugs and professional training in two research communes 2008 2009 Variables (Before intervene) (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 1.5 By self - CHCs 0.27 1.24 By the project, organization donors 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 Number of visits to Before After CHCs P value intervention intervention (6-first monthst) n % (6-last months) n % Dao ethnic Total visits 703 41.95 973 58.05 Gynecological 58 19.85 234 80.15 0.05 Gynecological 79 21.23 293 78.77