새천년개발목표(MDGs) 수립에 따른 KOICA 보건 분야 전략 및 사업변화 연구

학위논문 (석사)-- 서울대학교 대학원 : 보건학과, 2017. 2. 김창엽.2000년 UN 제 55차 정기 총회에서 전 세계 189개국 정상들은 향후 15년간 새천년개발목표(Millenium Development Goals, MDGs) 달성을 목표로 함께 노력할 것을 합의하였다. 이는 빈곤퇴치가 전 세계 개발협력의 주요한 목적이 되어야 한다는 강력한 정치적 합의로 평가된다. 하지만 선언에서 그치지 않고 목표를 달성하기 위해서는 여러 가지 다양한 측면의 노력들이 필요하다. 수원국 차원의 노력 이외에도 공여기관 역시 원조전략에 MDGs 달성을 높은 우선순위에 두고, 여러 가지 이행수단과 연계하여 자원을 효율적으로 배분하기 위한 노력이 필요하다. 특히 MDGs에 보건 분야 목표가 상당부분(8개 목표 중 3개 목표) 포함되어 있으며, 따라서 MDGs 이후, 공여국 한국의 보건원조 전략과 이행에는 어떠한 변화가 있었는지, 동 연구를 통해 살펴보고자 하였다. 이를 확인하기 위해, 국내 대표적인 원조기관인 한국국제협력단(KOICA)의 보건 분야 전략과 사업 규모의 양적 질적 변화를 분석하였다. 먼저 보건사업 관련 전략 및 가이드라인을 살펴본 결과, 수원국 개발환경 분석 등의 과정에서, MDGs가 비교적 상위 우선순위로 고려되었음을 확인할 수 있었다. 또한 사업 형성 및 이행, 평가와 관련된 가이드라인 수준의 전략에도 MDGs가 명시되고 고려되고 있었다. 반면, MDGs 달성 노력이 실제로 구현되어 가시적인 성과를 보이는 데에는 한계가 있었다. 예를 들어, 사업 심사 등 중요한 의사결정 과정에서는 MDGs에 관한 기준이 없어, 실제 이행과 연결되는 시점에서는 MDGs가 높은 우선순위로 고려되지 못하였다. 보건사업의 양적 규모 변화는 MDGs 이후, 총 원조액과 보건 분야 원조액 모두 크게 상승했음을 확인 할 수 있었지만, 총 원조 중 보건사업이 차지하는 비율이 지속적으로 증가하였다고 보기는 힘들었다. 특정 년도에 보건 분야 사업 비율이 높았으며, 이는 인프라 요소가 많이 포함된 대형 사업 등이 추진에 기인한다. 보건 분야의 질적 변화는 MDGs 선언 이후, 2005-2016년 기간 동안 시행된 150개의 보건사업을 대상으로 살펴보았으며, MDGs가 다루고 있는 아동사망률 감소 및 모성사망률 감소 등의 목표를 제시한 보건사업이 크게 증가하였으며, MDGs 이전에는 다루지 않았던 MDGs 6번과 관계된 HIV/AIDS 및 결핵과 관련된 사업도 적은 수이긴 하지만 시행되었다. 또한 MDGs 이전의 부문별 문제해결 중심 접근에서 벗어나, 통합적 접근으로 사업이 변화하였음을 확인 할 수 있었다. 수원국의 단기 요청에 대응하는 수준이 아닌 좀 더 수원국의 포괄적인 수요를 찾고자 하였고, 의료체계 강화 사업 등 포괄적 지역의 보건의료 환경과 보건 의료 수준 등을 다각적으로 고려하고, 지역의 보건문제 해소를 위한 사업의 개수가 증가하였다. 또한 사업의 방식 다각화도 주요한 변화이다. MDGs 이전의 독자적인 사업추진에서 벗어나 다양한 개발협력 파트너들과의 협력이 강화되었다. 이는 MDGs의 영향도 있지만, KOICA의 예산이 늘어 협력할 여지가 많아진 측면도 있다. MDGs 종료 이후, 2030년까지 전 세계가 달성해야할 지속가능개발목표(SDGs)가 수립되었고, 여러 이행수단 및 전략에 대해 논의가 진행되고 있다. KOICA를 비롯한 한국의 타 원조기관들도 기관의 비전 혹은 역할로 SDGs 이행·지원을 주요한 내용으로 선정할 것으로 예상된다. 따라서 SDGs 이행이 국제적 합의가 선언에서 그치지 않고 현실에서 구현되기 위해서는 전략에 이행을 위한 사항이 반영되어야 함을 물론, 실제 공여기관 및 직원들의 행동을 변화시킬 수 있는 제도 속에서 전략이 구현되어야 한다. 예를 들어 SDGs 이행을 보다 높은 우선순위에 두고 사업을 형성, 이행, 평가하기 위해서는 심사제도 역시 제도적 개선이 필요하다. 심사항목과 기준에 SDGs 기여도 등의 내용을 구체적으로 제시할 필요가 있다. 그리고 SDGs 이행 성과체계를 초기에 구축하여, 사업 평가 시, 점검하도록 해야 한다.Ⅰ. 서론 1 1. 연구 배경 1 2. 연구의 필요성 4 3. 연구목적과 연구질문 5 Ⅱ. 이론적 배경 5 1. 보건 분야 공적개발원조(ODA) 5 2. 새천년개발목표(Millennium Development Goals, MDGs) 7 3. 보건 분야 한국 무상원조 사업 추진 절차 고찰 12 Ⅲ. 연구 방법 15 1. 연구 설계 15 2. 연구 모형 16 3. 자료 수집 18 4. 타당도와 신뢰도 확보 20 Ⅳ. 연구 결과 20 1. 원조 전략 변화 20 2. 사업 집행 가이드라인 변화 36 3. 보건사업 변화 42 Ⅴ. 결론 53 1. 요약 및 제언 53 2. 연구의 한계 57 참고문헌 59 부록 63 Abstract 76Maste

Association of smoking with incident CKD risk in the general population: A community-based cohort study

Background: Chronic kidney disease (CKD) is a public health problem, and an unfavorable lifestyle has been suggested as a modifiable risk factor for CKD. Cigarette smoking is closely associated with cardiovascular disease and cancers; however, there is a lack of evidence to prove that smoking is harmful for kidney health. Therefore, we aimed to determine the relationship between cigarette smoking and CKD among healthy middle-aged adults. Methods: Using the database from the Korean Genome and Epidemiology Study, we analyzed 8,661 participants after excluding those with baseline estimated glomerular filtration rate (eGFR)<60 ml/min/1.72 m2 or proteinuria. Exposure of interest was smoking status: never-, former-, and current-smokers. Primary outcome was incident CKD defined as eGFR <60 ml/min/1.73 m2 or newly developed proteinuria. Results: The mean age of the subjects was 52 years, and 47.6% of them were males. There were 551 (6.4%) and 1,255 (14.5%) subjects with diabetes and hypertension, respectively. The mean eGFR was 93.0 ml/min/1.73 m2. Among the participants, 5,140 (59.3%), 1,336 (15.4%), and 2,185 (25.2%) were never-smokers, former-smokers, and current-smokers, respectively. During a median follow-up of 11.6 years, incident CKD developed in 1,941 (22.4%) subjects with a crude incidence rate of 25.1 (24.0-26.2) per 1,000 person-years. The multivariable Cox regression analysis after adjustment of confounding factors showed hazard ratios (95% confidence interval) of 1.13 (0.95-1.35) and 1.26 (1.07-1.48) for CKD development in the former- and current-smokers, compared with never-smokers. Conclusion: This study showed that smoking was associated with a higher risk of incident CKD among healthy middle-aged adults.ope

Carbohydrate-Rich Diet Is Associated with Increased Risk of Incident Chronic Kidney Disease in Non-Diabetic Subjects

Despite the potential relationship with metabolic derangements, the association between dietary carbohydrate intake and renal function remains unknown. The present study investigated the impact of dietary carbohydrate intake on the development of incident chronic kidneydisease (CKD) in a large-scale prospective cohort with normal renal function. A total of 6746 and 1058 subjects without and with diabetes mellitus (DM) were analyzed, respectively. Carbohydrate intake was assessed by a 24-h dietary recall food frequency questionnaire. The primary endpoint was CKD development, defined as a composite of estimated glomerular filtration rate (eGFR) of ≤60 mL/min/1.73 m2 and the development of proteinuria. CKD newly developed in 20.1% and 36.0% of subjects during median follow-ups of 140 and 119 months in the non-DM and DM subjects, respectively. Categorization of non-DM subjects into dietary carbohydrate density quartiles revealed a significantly higher risk of CKD development in the third and fourth quartiles than in the first quartile (P = 0.037 for first vs. third; P = 0.001 for first vs. fourth). A significant risk elevation was also found with increased carbohydrate density when carbohydrate density was treated as a continuous variable (P = 0.008). However, there was no significant difference in the incident CKD risk among those with DM according to dietary carbohydrate density quartiles. Carbohydrate-rich diets may increase the risk of CKD development in non-DM subjects.ope

Association Between Serum High-Density Lipoprotein Cholesterol Levels and Progression of Chronic Kidney Disease: Results From the KNOW-CKD

Background High-density lipoprotein cholesterol ( HDL -C) levels are generally decreased in patients with chronic kidney disease ( CKD ). However, studies on the relationship between HDL -C and CKD progression are scarce. Methods and Results We studied the association between serum HDL -C levels and the risk of CKD progression in 2168 participants of the KNOW - CKD (Korean Cohort Study for Outcome in Patients With Chronic Kidney Disease). The primary outcome was the composite of a 50% decline in estimated glomerular filtration rate from baseline or end-stage renal disease. The secondary outcome was the onset of end-stage renal disease. During a median follow-up of 3.1 (interquartile range, 1.6-4.5) years, the primary outcome occurred in 335 patients (15.5%). In a fully adjusted Cox model, the lowest category with HDL -C of <30 mg/dL (hazard ratio, 2.21; 95% CI, 1.30-3.77) and the highest category with HDL -C of ≥60 mg/dL (hazard ratio, 2.05; 95% CI , 1.35-3.10) were associated with a significantly higher risk of the composite renal outcome, compared with the reference category with HDL -C of 50 to 59 mg/dL. This association remained unaltered in a time-varying Cox analysis. In addition, a fully adjusted cubic spline model with HDL -C being treated as a continuous variable yielded similar results. Furthermore, consistent findings were obtained in a secondary outcome analysis for the development of end-stage renal disease. Conclusions A U-shaped association was observed between serum HDL -C levels and adverse renal outcomes in this large cohort of patients with CKD . Our findings suggest that both low and high serum HDL -C levels may be detrimental to patients with nondialysis CKD .ope

Dietary zinc intake and incident chronic kidney disease

Background & aims: Previous studies have shown that dietary zinc intake is closely related to cardiovascular complications and metabolic derangements. However, the effect of dietary zinc intake on renal function is not fully elucidated. Methods: Data from the Korean Genome and Epidemiology Study were used. Dietary zinc intake was assessed by a Food Frequency Questionnaire and dietary zinc density was calculated as absolute zinc intake amount per daily energy intake (mg/1000 kcal day). The participants were categorized into quartiles according to dietary zinc density. The primary end point was incident chronic kidney disease (CKD), defined as estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2. Results: A total of 7735 participants with normal renal function was included in the final analysis. The mean age was 52.0 ± 8.8 years, 47.5% were male, and mean eGFR was 92.1 ± 16.1 ml/min/1.73 m2. The mean daily zinc intake and zinc intake density were 8.6 ± 3.4 mg and 4.4 ± 0.9 mg/1000 kcal, respectively. During a median follow up of 11.5 (1.7-12.5) years and 70,617 person-years of observation, CKD developed in 1409 (18.2%) participants. Multivariable cox hazard analysis revealed that risk for CKD development was significantly higher in the quartile with a mean zinc intake density of 3.6 ± 0.2 mg/1000 kcal compared with the quartile with a mean zinc intake density of 5.6 ± 1.0 mg/1000 kcal (Hazard ratio; 1.36; 95% Confidence Interval 1.18-1.58; P < 0.001). This relationship remained significant even after adjustments for confounding factors. Conclusion: Low dietary zinc intake may increase the risk of CKD development in individuals with normal renal function.ope

Framingham risk score and risk of incident chronic kidney disease: A community-based prospective cohort study

Background: Cardiovascular disease and chronic kidney disease share several common risk factors. The Framingham risk score is hypothesized to predict chronic kidney disease development. We determined if the Framingham risk scoring system can correctly predict incident chronic kidney disease in the general population. Methods: This study included 9,080 subjects who participated in the Korean Genome and Epidemiology Study between 2001 and 2014 and had normal renal function. The subjects were classified into low- ( 20%) risk groups based on baseline Framingham risk scores. The primary endpoint was de novo chronic kidney disease development (estimated glomerular filtration rate [eGFR], < 60 mL/min/1.73 m2). Results: During a mean follow-up duration of 8.9 ± 4.3 years, 312 (5.3%), 217 (10.8%), and 205 (16.9%) subjects developed chronic kidney disease in the low, intermediate, and high risk groups, respectively (P < 0.001). Multivariable analysis after adjustment for confounding factors showed the hazard ratios for the high- and intermediate risk groups were 2.674 (95% confidence interval [CI], 2.197-3.255) and 1.734 (95% CI, 1.447-2.078), respectively. This association was consistently observed irrespective of proteinuria, age, sex, obesity, or hypertension. The predictive power of this scoring system was lower than that of renal parameters, such as eGFR and proteinuria, but increased when both were included in the prediction model. Conclusion: The Framingham risk score predicted incident chronic kidney disease and enhanced risk stratification in conjunction with traditional renal parameters in the general population with normal renal function.ope

Snoring and incident chronic kidney disease: a community-based prospective cohort study

OBJECTIVES: Previous studies have shown that symptoms of sleep-disordered breathing are associated with metabolic derangements and vascular disease development. However, the relationship between snoring and renal function is not well investigated. The association between snoring and the development of incident chronic kidney disease (CKD) in subjects with normal renal function was evaluated. DESIGN: Prospective cohort study. SETTING: Ansung (rural community) and Ansan (urban community) cities. PARTICIPANTS: Community-based cohort participants aged 40-69 years. METHODS: A total of 9062 participants in the Ansung-Ansan cohort study were prospectively followed up from 2001 to 2014. The participants were classified into three groups: non-snorer, <1 day/week and ≥1 day/week. The main outcome was incident CKD, which was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m2 during the follow-up period. PRIMARY OUTCOME: Incident CKD. RESULTS: The mean subject age was 52.0±8.9 years, and 4372 (48.2%) subjects were male. The non-snorer,<1 day/week and ≥1 day/week groups included 3493 (38.5%), 3749 (41.4%), and 1820 (20.1%) subjects, respectively. Metabolic syndrome was more prevalent in the snoring groups than in the non-snoring group. Snoring frequency showed a significant positive relationship with age, waist:hip ratio, fasting glucose, total cholesterol (Tchol) and low-density lipoprotein cholesterol. During a mean follow-up of 8.9 years, 764 (8.4%) subjects developed CKD. Cox proportional hazards model analysis revealed that the risk of CKD development was significantly higher in subjects who snored ≥1 day/week than in non-snorers, even after adjustments for confounding factors (HR 1.23, 95% CI 1.09 to 1.38, p<0.01). CONCLUSION: Snoring may increase the risk of CKD development in subjects with normal renal function.ope

Study on the factor affecting social accountability and the indicators of medical schools

This study aims to increase medical schools’ autonomous capabilities to foster social accountability by identifying the factors affecting the implementation of social accountability by medical schools and by developing social accountability indicators for accreditation of medical schools. In addition, the study intends to broaden the concept of medical school accreditation to include social accountability and to change the accreditation paradigm to become rooted in social accountability. Specifically, this study intends to carry out the following research. First,we identify the factors influencing medical schools’ social accountability. Second, we categorize and characterize the types of social accountability implemented by medical schools. Third, we analyze the perception of the importance of factors affecting social accountability implementation and the current situation in medical schools. Fourth, we develop the indicators for measuring the implementation of social accountability by medical schools. To identify the factors that influence the implementation of social accountability by medical schools, a total of 55 responses, comprised of 40 responses from current deans of medical schools and 15 from medical education experts in the Republic of Korea, were included in the final analysis. In addition, the opinions of 40 medical schools in Korea were collected to categorize the types of social responsibility fulfillment and to analyze the recognition of its importance and the current situation in medical schools. We developed the survey used in this study. It was titled “Opinion Survey on the Importance and Status of Factors Influencing the Implementation of Social Accountability by Medical Schools.” The data was analyzed by means of descriptive statistics and calculating the differences between groups, the exploratory factor analysis, multiple regression analysis, cluster analysis, and importance and performance analysis (IPA). To develop the measurement indicators of medical schools’ social accountability, the opinions of the focus group comprised of four experts and the opinions of 15 medical education experts were collected. The following survey items were used: experts' opinions on the selection of [ASK2019] standards regarding medical schools’ social accountability, experts' opinions on the selection of [ASK2019] standards based on the social accountability grid, and experts' opinions on the suitability and ease of measurement of indicators based on [ASK2019] of medical schools’ social accountability. The results of our research are as follows. First, based on the HSP model, eight factors in three areas influenced the implementation of social accountability by medical schools. The hardware (H) area included the announcement of social accountability and personnel discharge, implementation system and organization, and the physical and financial factors. The software (S) area included the social accountability curriculum composition, monitoring, and evaluation factors. Finally, the partner (P) area included the proximity between partners, partnership building, and interaction with partners factors. Among them, interaction with partners was the biggest factor in the implementation of social accountability by medical schools. In addition, the difference between the deans’ group and the experts’ group demonstrated that the deans’ group scored high across all factors. Among the factors, the deans’ group recognized the social accountability announcement, personnel discharge, social accountability curriculum organization, and performance organization and system factors as important. Second, the analysis of the implementation of social accountability by medical schools classified them into three groups depending on their position on the implementation of social accountability spectrum: leading, growing, and medical schools with potential to grow. Five out of 40 medical schools were selected as leading based on the eight factors implemented in balance. As a result of analyzing the importance and current level of medical schools’ social accountability by type, location, and the year of establishment in the Republic of Korea, the level of state schools was higher than that of the private schools, and there was no statistically significant difference based on the location and year of establishment. Third, as a result of selecting the [ASK2019] standards related to medical schools’ social accountability, a total of 92 criteria were selected. These included 61 criteria that were selected through focus group discussions for the social grid model, and 41 criteria that were selected based on the opinions of the expert group. As a result of classification in the social accountability grid model, Korean Institute of Medical Education and Evaluation (KIMEE) standards were similar to foreign evaluation and accreditation standards(WFME, LCME, AMC)and focused on educational relevance, but the [ASK2019] indicated that in the area of education and quality, education was more important. In addition, the area of research and service and the standards of cost effectiveness and equity needed to be investigated further. Fourth, a total of 252 quantitative and qualitative indicators were developed for 41 of the basic [ASK2019] criteria that reflected medical schools’ social accountability. Among them, the evaluation matrix for the [ASK2019] basic criteria was developed to reflect medical schools’ social accountability for the indicators of 3.5 points or higher by collecting additional opinions on the suitability and ease of measurement. The discussion in this study suggested the development of a joint consortium between medical schools, communities, countries, and regions, because building partnerships and interactions is important to strengthen the implementation of social accountability by medical schools. Also, the study proposed to actively consider and reflect the criteria and indicators of medical schools’ social accountability in the current evaluation and accreditation system. Finally, the degrees of social accountability implementation by medical schools may vary depending on the context, situation, and specialization of medical schools. Therefore, efforts are needed to establish social accountability implementation mechanisms for individual medical schools. 이 연구의 목적은 의과대학이 자율적으로 사회적 책무성 역량을 촉진시키는데 있다. 아울러, 의과대학의 사회적 책무성을 의과대학 평가인증까지 개념을 확장시켜 사회적 책무성에 입각한 평가인증 패러다임을 전환하는데 기여하고자 한다. 이 연구에서 수행하고자 하는 구체적인 연구 내용은 다음과 같다. 첫째, 의과대학의 사회적 책무성 수행 영향요인을 규명한다. 둘째, 의과대학의 사회적 책무성 수행 유형을 범주화하고 특성을 분석한다. 셋째, 사회적 책무성 수행 영향요인의 중요도에 대한 인식과 의과대학의 현황을 분석한다. 넷째, 의과대학의 사회적 책무성 수행 측정을 위한 지표를 개발한다. 의과대학의 사회적 책무성 수행에 영향을 미치는 요인을 규명하기 위해 국내 의과대학의 현직 학장 40명과 의학교육 전문가 집단 15명을 대상으로 총 55명의 자료가 최종 분석에 포함되었다. 또한 의과대학의 사회적 책무성 수행 유형 범주화와 중요도 인식과 대학의 현황을 분석하기 위해 국내 40개 의과대학의 의견을 수렴하였다. 연구에 사용된 조사도구는 연구자가 개발한 ‘의과대학의 사회적 책무성 수행 영향요인 중요도와 현황에 관한 의견 조사지’이다. 자료 분석은 기술통계와 집단 간 차이검정, 탐색적 요인분석과 다중회귀분석, 군집분석, 중요도-현황 분석(IPA)을 실시하였다. 의과대학의 사회적 책무성 수행 측정지표를 개발하기 위해 4명의 전문가 포커스 그룹과 15명의 의학교육 관련 전문가 집단 의견을 수렴하였다. 포커스 그룹과 델파이 그룹은 각각 3차례씩 의견 수렴이 진행되었다. 의과대학의 사회적 책무성 수행 영향요인 규명과 측정지표 개발에 관한 연구결과는 다음과 같다. 첫째, 의과대학의 사회적 책무성 수행에 영향을 주는 요인은 3영역의 8요인이다. 하드웨어 영역은 사회적 책무성 선언과 인력배출, 수행 조직과 체계, 물리·재정적 환경 요인이 포함된다. 소프트웨어 영역은 책무성 교육과정 편성과 모니터링과 평가 요인이다. 마지막으로 파트너영역은 파트너간 근접성, 파트너십 구축, 파트너와의 상호작용 요인이 포함된다. 이 중 파트너와의 상호작용은 의과대학의 사회적 책무성을 수행하는데 가장 큰 요인으로 작용하였다. 아울러, 학장집단과 전문가집단의 차이는 전체적인 요인에서 학장 집단이 높았으며, 그 중 학장 집단은 사회적 책무성 선언과 인력 배출, 책무성 교육과정 편성, 수행 조직과 체계 등을 중요하게 인식하고 있다. 둘째, 의과대학의 사회적 책무성 수행 현황을 분석한 결과 크게 선도형 대학, 성장형 대학, 잠재형 대학으로 구분된다. 선도형 대학은 40개 대학 중 5개 대학이 선정되었으며, 8개 요인을 균형적으로 수행하고 있었다. 한국적 맥락에 따른 설립유형, 소재지, 설립연도별로 의과대학의 사회적 책무성 수행 중요도와 현재수준을 분석한 결과, 국립이 사립보다 현재 수준이 높았으며, 그 외에 소재지와 설립연도별에서는 통계적으로 유의한 차이는 없었다. 셋째, 의과대학의 사회적 책무성과 관련한 「ASK2019」기준을 선정한 결과, 92개 기본 기준 중 사회적 그리드 모형으로 포커스 그룹을 통해 61개 기준이 선정되었고, 전문가 집단의 의견수렴에서는 41개 기준이 선정되었다. 사회적 그리드 모형으로 분류한 결과 「ASK2019」기준은 교육과 질 영역, 내용을 중요하게 평가하고 있다. 연구와 질, 비용효과성과 형평성에 대한 기준 개발 및 조정이 필요하다. 넷째, 의과대학의 사회적 책무성을 반영한 「ASK2019」기본 기준 중 41개 기준을 대상으로 측정지표를 정량적 지표와 정성적 지표로 나뉘어 총 252개 지표를 개발하였다. 그 중 측정지표의 적합성과 측정용이성에 대한 추가 의견을 수렴하여 각 영역에서 3.5점 이상의 지표를 대상으로 의과대학의 사회적 책무성을 반영한 「ASK2019」기본기준의 평가 매트릭스를 개발하였다. 이 연구의 논의는 의과대학의 사회적 책무성 수행 강화를 위해 파트너십 구축과 상호작용이 중요하므로 대학 간, 국가 및 지역 간의 공동 컨소시엄 개발을 제언하였다. 또한 의과대학의 사회적 책무성과 관련한 기준과 지표를 현 평가인증 제도에서 적극적으로 고려하고 반영하는 것을 제안하였다. 마지막으로 의과대학이 처한 맥락과 상황, 주체에 따라 의과대학의 사회적 책무성 수행정도는 달라질 수 있으므로, 개별 의과대학의 사회적 책무성 수행 메커니즘 구축을 위한 노력이 필요하다.open박

(A) study on differences between consumers and nurses of perception of customer-oriented core values for quality nursing services

간호학과/박사[한글] 오늘날 병원경영이 고객중심, 서비스중심으로 변화하면서 보다 우수한 간호서비스품질관리가 요구되고 있다. 본 연구는 고객과 간호사간의 간호서비스품질 핵심가치에 대한 인식의 차이를 파악하여 고객지향의 맞춤 간호서비스 제공 의사결정 과정을 지원하는데 기초를 마련하고자 시도하였다. 1998년도부터 한국생산성본부가 실시한 국가고객만족도(National customer satisfaction indication : NCSI)조사 결과 6년 동안 1위부터 3위를 차지하였던 4개 3차 의료기관의 고객과 간호사를 대상으로 2003년 2월부터 4월까지 2개월간 내, 외과계 입원 고객 313명 간호사 315명을 대상으로 Parasuraman 등(1991)이 제시한 SERVQUAL모델을 기반으로 입원환자 중증도 분류지표로 사용되는 8개의 기본간호서비스 영역을 가지고 연구자가 개발한 간호서비스품질 측정도구에 의해 고객과 간호사간의 인식의 차이를 측정한 횡단적 비교분석연구이다. 연구결과는 다음과 같다. 1) 주 가설 검증결과 1)-1. ''간호서비스품질에 대한 고객의 사전기대와 간호사의 사전인식에는 차이가 있을 것이다.''라는 제 1가설은 신뢰성, 신속성, 보증성, 공감성에서 간호사의 사전 인식정도가 높게 통계적으로 유의한 차이를 나타냈다. 1)-2. ''간호서비스품질에 대한 고객의 사전 기대와 간호사의 사후평가 인식에는 차이가 있을 것이다.'' 라는 제 2가설은 외형성에서 간호사의 사후평가 인식정도가 낮게 통계적으로 유의한 차이를 나타냈다. 1)-3. ''간호사의 사전인식과 사후평가 인식에는 차이가 있을 것이다.''라는 제 3가설은 외형성, 신뢰성, 신속성, 보증성, 공감성에서 사전인식정도에 비해 사후평가 인식정도가 낮게 통계적으로 유의한 차이를 나타냈다. 1)-4. ''고객의 사후평가 인식과 간호사의 사후평가 인식에는 차이가 있을 것이다.''라는 제 4가설은 외형성에서 고객보다 간호사가 낮게 통계적으로 유의한 차이를 나타냈다. 1)-5. ''간호서비스품질에 대한 고객의 사전기대와 사후평가 인식에는 차이가 있을 것이다.''라는 제 5가설은 외형성, 신뢰성, 신속성, 보증성, 공감성에서 사전기대 보다 사후평가 인식정도가 낮게 통계적으로 유의한 차이를 나타냈다. 1)-6. ''고객과 간호사의 간호서비스품질 중요도 인식에는 차이가 있을 것이다.''라는 제 6가설은 간호서비스 품목에 따라 중요도 인식의 우선순위만 다르고 5가지 핵심가치를 모두 중요하게 인식하는 것으로 나타났다. 2) 부 가설 검증결과 2)-1. ''고객의 일반적 특성에 따른 간호서비스품질에 대한 사전기대, 사후평가 인식에는 차이가 있을 것이다''라는 제 1부 가설은 여성 고객일수록, 1인실과 특실 고객일수록, 간호서비스에 대해 전혀 경험이 없거나 긍정적인 경험이 있는 고객일수록, 긍정적인 외부 구전경험이 있는 고객일수록 사전기대와 사후평가 인식정도가 높게 유의한 차이를 나타냈다. 2)-2. ''간호사의 일반적 특성에 따른 사전인식, 사후평가 인식에는 차이가 있을 것이다''라는 제 2부 가설은 우수한 간호서비스품질을 제공하기 위해서 ''적정간호인력''이 가장 중요한 조건이라고 한 간호사일수록, 직위가 있는 경력 간호사일수록 사전 인식정도가 높았고, 간호사 개인역량이 우수한 간호서비스품질에 중요한 조건이라고 한 간호사일수록 사후평가 인식정도가 높게 유의한 차이를 나타냈다. 결론적으로 고객과 간호사의 간호서비스품질의 핵심가치 인식의 차이를 개선하기 위해 고객의 가치와 일치하는 품질을 제공하는 간호사의 의사결정과정을 지원하고, 효과적인 고객만족 실현을 위한 간호의 핵심가치 구현 시스템을 구축하여 간호서비스품질 개선 향상 방향을 모색함으로서 병원간호 서비스 마케팅 전략 수립에 기초가 되고 간호생산성과 병원수익성 증대 전략 수립에 기여할 수 있을 것으로 기대한다. 핵심되는말 : 고객지향적. 간호서비스품질. 핵심가치. 인식 [영문] Consumers'' and nurses'' perceptions of nursing services in a medical-surgical department were compared and analyzed in this study. The purpose of the study was to measure differences of perceptions that could be used to evaluate the quality of nursing services by identifying consumers'' expectation and nurses'' perception of nursing services according to the SERVQUAL model. The participants were 315 nurses and 313 consumers from tertiary general hospitals ranked first to third in evaluation by the NCSI (National Customer Satisfaction Indication). Data collection was done in 4 tertiary general hospitals in Seoul from February to April 2003. The data were analyzed with descriptive statistics, t-test, paired t-test, and ANOVA using the SAS program. Delphi was used for the research tool and the results of the research are as follows: Five nursing service core values to measure the quality of nursing service were identified, Tangibility, Reliability, Responsiveness, Assurance, and Empathy. 1) The main hypothesis were as follows: Hypothesis 1 that there will be a difference between consumers'' prior expectations of the quality of nursing services and nurses'' prior perceptions of consumers'' expectations was accepted for Reliability, Responsiveness, Assurance, and Empathy (p<.01). Hypothesis 2 that there will be a difference between consumers'' prior expectations of the quality of nursing services and the quality of nursing services actually provided was accepted for Tangibility (p<.01). Hypothesis 3 that consumers'' expectations of quality of nursing services and perception of actual quality of nursing will be different was accepted for Tangibility, Reliability, Responsiveness, Assurance, and Empathy (p<.01). Hypothesis 4 that there will be a difference between consumer evaluation and nurses'' evaluation of actual quality of nursing service was accepted for Reliability (p<.01). Hypothesis 5 that there will be a difference between consumers'' prior expectations of nursing services and evaluation after service was supported for Tangibility (p<.01). For Hypothesis 6 that there will be a difference between consumers and nurses regarding perception of the important core values for quality of each nursing service, only two items ''examination and treatment'' and ''education and emotional support'', were the same for both two groups. Perception was different for all other services. Examination of prior expectation of quality of nursing services according to demographic characteristics of the consumers, showed that women, those in private rooms, those with no experience with nursing services or positive experience, and those with no experience with quality of nursing services or positive experience had higher prior expectations and higher perception in evaluation of nursing service. Examination of prior perception of consumers'' expectations according to demographic characteristics of the nurses, showed that the most important factor was the need to have enough personnel to be able to give quality nursing service. Experienced nurses reported higher perceptions of consumers'' expectations, in the post evaluation, nurses who stressed the need for high quality nursing services had high evaluation scores. In this research based on the SERVQUAL Model by Parasuraman, A., et al. (1991), expectations, perceptions and customer-oriented nursing services were examined. According to the results of the research, nurses should try to decrease the differences between customers and nurses in the perception of customer-oriented the core value of nursing services quality. As a result of the above research, nurses can improve the quality of nursing service by reducing the difference between customers'' and nurses'' perceptions of core values of nursing through support of a nursing decision making process that provides quality consistent with the customers'' core values. This study provides basic data to contribute to the realization of effective customer satisfaction, the development of a system of nursing core values, the examination of ways to improve the quality of nursing service, and it provides a basis for marketing strategies for hospital nursing services and establishes strategies to increase nursing outcomes and hospital finances. Key Words : Customer - orientation . Quality of nursing services . Core value. Perceptionope

우방자의 세포성장 억제 성분에 관한 연구

학위논문(석사)--서울대학교 대학원 :약학과 약품분석화학전공,2003.Maste