• 대한간호학회지
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• 제3권1호
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• pp.13-40
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• 1972

Much has teed changed in the field of hospital administration in the It wake of the rapid development of sciences, techniques ana systematic hospital management. However, we still have a long way to go in organization, in the quality of hospital employees and hospital equipment and facilities, and in financial support in order to achieve proper hospital management. The above factors greatly effect the ability of hospitals to fulfill their obligation in patient care and nursing services. The purpose of this study is to determine the optimal methods of standardization and quality nursing so as to improve present nursing services through investigations and analyses of various problems concerning nursing administration. This study has been undertaken during the six month period from October 1971 to March 1972. The 41 comprehensive hospitals have been selected iron amongst the 139 in the whole country. These have been categorized according-to the specific purposes of their establishment, such as 7 university hospitals, 18 national or public hospitals, 12 religious hospitals and 4 enterprise ones. The following conclusions have been acquired thus far from information obtained through interviews with nursing directors who are in charge of the nursing administration in each hospital, and further investigations concerning the purposes of establishment, the organization, personnel arrangements, working conditions, practices of service, and budgets of the nursing service department. 1. The nursing administration along with its activities in this country has been uncritical1y adopted from that of the developed countries. It is necessary for us to re-establish a new medical and nursing system which is adequate for our social environments through continuous study and research. 2. The survey shows that the 7 university hospitals were chiefly concerned with education, medical care and research; the 18 national or public hospitals with medical care, public health and charity work; the 2 religious hospitals with medical care, charity and missionary works; and the 4 enterprise hospitals with public health, medical care and charity works. In general, the main purposes of the hospitals were those of charity organizations in the pursuit of medical care, education and public benefits. 3. The survey shows that in general hospital facilities rate 64 per cent and medical care 60 per-cent against a 100 per cent optimum basis in accordance with the medical treatment law and approved criteria for training hospitals. In these respects, university hospitals have achieved the highest standards, followed by religious ones, enterprise ones, and national or public ones in that order. 4. The ages of nursing directors range from 30 to 50. The level of education achieved by most of the directors is that of graduation from a nursing technical high school and a three year nursing junior college; a very few have graduated from college or have taken graduate courses. 5. As for the career tenure of nurses in the hospitals: one-third of the nurses, or 38 per cent, have worked less than one year; those in the category of one year to two represent 24 pet cent. This means that a total of 62 per cent of the career nurses have been practicing their profession for less than two years. Career nurses with over 5 years experience number only 16 per cent: therefore the efficiency of nursing services has been rated very low. 6. As for the standard of education of the nurses: 62 per cent of them have taken a three year course of nursing in junior colleges, and 22 per cent in nursing technical high schools. College graduate nurses come up to only 15 per cent; and those with graduate course only 0.4 per cent. This indicates that most of the nurses are front nursing technical high schools and three year nursing junior colleges. Accordingly, it is advisable that nursing services be divided according to their functions, such as professional, technical nurses and nurse's aides. 7. The survey also shows that the purpose of nursing service administration in the hospitals has been regulated in writing in 74 per cent of the hospitals and not regulated in writing in 26 per cent of the hospitals. The general purposes of nursing are as follows: patient care, assistance in medical care and education. The main purpose of these nursing services is to establish proper operational and personnel management which focus on in-service education. 8. The nursing service departments belong to the medical departments in almost 60 per cent of the hospitals. Even though the nursing service department is formally separated, about 24 per cent of the hospitals regard it as a functional unit in the medical department. Only 5 per cent of the hospitals keep the department as a separate one. To the contrary, approximately 12 per cent of the hospitals have not established a nursing service department at all but surbodinate it to the other department. In this respect, it is required that a new hospital organization be made to acknowledge the independent function of the nursing department. In 76 per cent of the hospitals they have advisory committees under the nursing department, such as a dormitory self·regulating committee, an in-service education committee and a nursing procedure and policy committee. 9. Personnel arrangement and working conditions of nurses 1) The ratio of nurses to patients is as follows: In university hospitals, 1 to 2.9 for hospitalized patients and 1 to 4.0 for out-patients; in religious hospitals, 1 to 2.3 for hospitalized patients and 1 to 5.4 for out-patients. Grouped together this indicates that one nurse covers 2.2 hospitalized patients and 4.3 out-patients on a daily basis. The current medical treatment law stipulates that one nurse should care for 2.5 hospitalized patients or 30.0 out-patients. Therefore the statistics indicate that nursing services are being peformed with an insufficient number of nurses to cover out-patients. The current law concerns the minimum number of nurses and disregards the required number of nurses for operation rooms, recovery rooms, delivery rooms, new-born baby rooms, central supply rooms and emergency rooms. Accordingly, tile medical treatment law has been requested to be amended. 2) The ratio of doctors to nurses: In university hospitals, the ratio is 1 to 1.1; in national of public hospitals, 1 to 0.8; in religious hospitals 1 to 0.5; and in private hospitals 1 to 0.7. The average ratio is 1 to 0.8; generally the ideal ratio is 3 to 1. Since the number of doctors working in hospitals has been recently increasing, the nursing services have consequently teen overloaded, sacrificing the services to the patients. 3) The ratio of nurses to clerical staff is 1 to 0.4. However, the ideal ratio is 5 to 1, that is, 1 to 0.2. This means that clerical personnel far outnumber the nursing staff. 4) The ratio of nurses to nurse's-aides; The average 2.5 to 1 indicates that most of the nursing service are delegated to nurse's-aides owing to the shortage of registered nurses. This is the main cause of the deterioration in the quality of nursing services. It is a real problem in the guest for better nursing services that certain hospitals employ a disproportionate number of nurse's-aides in order to meet financial requirements. 5) As for the working conditions, most of hospitals employ a three-shift day with 8 hours of duty each. However, certain hospitals still use two shifts a day. 6) As for the working environment, most of the hospitals lack welfare and hygienic facilities. 7) The salary basis is the highest in the private university hospitals, with enterprise hospitals next and religious hospitals and national or public ones lowest. 8) Method of employment is made through paper screening, and further that the appointment of nurses is conditional upon the favorable opinion of the nursing directors. 9) The unemployment ratio for one year in 1971 averaged 29 per cent. The reasons for unemployment indicate that the highest is because of marriage up to 40 per cent, and next is because of overseas employment. This high unemployment ratio further causes the deterioration of efficiency in nursing services and supplementary activities. The hospital authorities concerned should take this matter into a jeep consideration in order to reduce unemployment. 10) The importance of in-service education is well recognized and established. 1% has been noted that on the-job nurses. training has been most active, with nursing directors taking charge of the orientation programs of newly employed nurses. However, it is most necessary that a comprehensive study be made of instructors, contents and methods of education with a separate section for in-service education. 10. Nursing services'activities 1) Division of services and job descriptions are urgently required. 81 per rent of the hospitals keep written regulations of services in accordance with nursing service manuals. 19 per cent of the hospitals do not keep written regulations. Most of hospitals delegate to the nursing directors or certain supervisors the power of stipulating service regulations. In 21 per cent of the total hospitals they have policy committees, standardization committees and advisory committees to proceed with the stipulation of regulations. 2) Approximately 81 per cent of the hospitals have service channels in which directors, supervisors, head nurses and staff nurses perform their appropriate services according to the service plans and make up the service reports. In approximately 19 per cent of the hospitals the staff perform their nursing services without utilizing the above channels. 3) In the performance of nursing services, a ward manual is considered the most important one to be utilized in about 32 percent of hospitals. 25 per cent of hospitals indicate they use a kardex; 17 per cent use ward-rounding, and others take advantage of work sheets or coordination with other departments through conferences. 4) In about 78 per cent of hospitals they have records which indicate the status of personnel, and in 22 per cent they have not. 5) It has been advised that morale among nurses may be increased, ensuring more efficient services, by their being able to exchange opinions and views with each other. 6) The satisfactory performance of nursing services rely on the following factors to the degree indicated: approximately 32 per cent to the systematic nursing activities and services; 27 per cent to the head nurses ability for nursing diagnosis; 22 per cent to an effective supervisory system; 16 per cent to the hospital facilities and proper supply, and 3 per cent to effective in·service education. This means that nurses, supervisors, head nurses and directors play the most important roles in the performance of nursing services. 11. About 87 per cent of the hospitals do not have separate budgets for their nursing departments, and only 13 per cent of the hospitals have separate budgets. It is recommended that the planning and execution of the nursing administration be delegated to the pertinent administrators in order to bring about improved proved performances and activities in nursing services.

• 지능정보연구
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• 제17권4호
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• pp.175-191
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• 2011

국가신성장동력으로MICE(Meeting, Incentive travel, Convention, Exhibition) 산업이각광받으면서국내전시산업에 대한 관심이 드높아 지고 있다. 이에 따라 국내 전시산업(domestic exhibition industry)도 미국이나 유럽과 같이 전시성과를 향상시키기 위한 다양한 연구가 진행 중이다. 그 중에서도 전시환경이나 전시기법 등에 따라 관람효과가 다르기 때문에 지능형 정보기술을 이용하여 전시장에 방문한 참관객의 참관패턴을 분석하여 참관객을 이해하고 더 나아가 참여업체 간의 연관관계 도출 및 전시회의 성과를 높이고자 하는 연구들이 진행되고 있다. 그런데, 이러한 기존의 부스추천시스템과 관련된 연구를 살펴보면 시스템적인 관점에서 추천의 정확성만을 논하고 있을 뿐 추천을 통한 참관객의 행동이나 인식의 변화에 대해서는 충분히 논의하고 있지 못하다. 부스추천시스템(Booth Recommendation System)은 참관객의 부스방문 정보를 바탕으로 참관객에게 적절한 부스를 추천하기 때문에 참관객은 사전에 계획하지 않은 전시장을 방문하게 될 수 있다. 이 때 참관객은 계획하지 않은 방문행동을 통해서 만족할 수도 있지만 추천과 정이 번거롭다거나 자유롭게 참관을 하는데 방해가 된다고 생각할 수 있다. 이 경우 참관객의 자유로운 관람보다 오히려 더 좋지 않은 성과를 낼 수 있다. 따라서 부스 추천시스템을 전시장에 적용하기 위해서는 시스템의 성과에 미치는 영향요인이 무엇인지 전반적으로 검토하고, 부스추천시스템이 참관객의 계획되지 않은 방문행동에 미치는 영향에 대해 면밀히 검토해야 한다. 이에 본 연구에서는 부스추천시스템의 성과에 영향을 미치는 요인이 무엇인지 이론과 기존문헌을 통해 살펴보고자 하였다. 또한, 참관객의 지각된 부스추천시스템의 성과가 참관객의 계획되지 않은 행동에 대한 만족도와 부스추천시스템의 재사용의도에 어떤 영향을 미치는지 살펴보고자 하였다. 이러한 연구목적을 달성하기 위한 이론적 프레임워크로 본 연구는 계획되지 않은 행동이론(Unplanned Behavior Theory)을 도입하였다. 계획되지 않은 행동(unplanned behavior)이란 "소비자들이 사전에 계획하지 되지 않은 채 실행된 어떤 행동"으로 정의할 수 있다. 소비자들의 계획되지 않은 행동은 그 동안 마케팅 등 다양한 분야에서 연구되어 왔다. 특히, 마케팅에서는 계획되지 않은 행동 중 계획되지 않은 구매(unplanned purchasing)에 많은 관심을 두어 왔는데 이 개념은 종종 충동적 구매(impulsive purchasing)와 혼동되어 사용되곤 하였다. 그런데, 충동적 구매가 갑자기 무엇인가 구매를 해야하는 강하고 지속적인 충동(urge)이라고 본다면 계획되지 않은 구매는 구매의사결정의 시점이 상점에 들어가기 전이 아닌 상점 내에서 수행된다는 점이 다르다. 즉, 모든 충동적 구매는 비계획적이나, 모든 계획되지 않은 구매가 충동적인 구매는 아니다. 그런데, 왜 소비자들은 계획되지 않은 행동을 하는가? 이에 대해서는 학자들에 따라 여러 가지 의견이 있으나 소비자가 사전에 철저한 계획을 수립하지 않고 따라서 중간에 계획을 변화시킬만한 유연성(flexibility)이 있기 때문이라는 점에 일관된 의견을 보인다. 즉, 계획되지 않은 행동을 하는데 많은 비용이 소요된다면 소비자들은 사전에 수립한 계획을 변경하기 어렵게 될 것이기 때문이다. 본 연구에서 살펴보고자 하는 전시장 역시 참관객들은 방문하기 전에 전시장이 어떤 프로그램으로 구성되어 있는지 살펴보고, 어떤 부스를 방문할지를 사전에 계획하게 된다. 그 이유는 참관객들이 전시장 방문에 투입할 수 있는 시간은 한정되어 있는 반면에 전시회는 대규모의 다양한 부스로 운영되기 때문에 참관객들이 모든 부스를 참관한다는 것이 현실적으로 불가능하기 때문이다. 따라서 본 연구에서 제시하는 부스추천시스템이 참관객이 선호할 만한 부스를 추천하게 되면 참관객은 자신의 계획을 변화시켜서 부스추천시스템이 추천한 부스를 방문하게 된다. 이러한 방문행동은 소비자가 상점을 방문하거나, 관광객이 관광지에서 계획하지 않은 행동을 하는 것과 유사한 측면에서 이해가 가능하며 특히 최근 여행소비자들이 정보기기의 영향으로 계획되지 않은 행동을 하는 경우가 부쩍 증가한 추세와 동일한 맥락에서 이해가 가능하다. 이에 다음과 같은 연구모형을 설정하였다. 이 연구모형은 참관객이 지각한 부스추천시스템의 성과(performance)를 매개변수로 하고 있는데 이 성과에 영향을 미치는 요인으로 부스추천시스템에 대한 신뢰(trust), 전시장 참관객의 지식수준 (knowledge level), 부스 추천시스템의 기대된 개인화 (expected personalization) 그리고 부스추천시스템의 자유위협(threat to freedom)을 영향요인으로 파악하였다. 또한, 지각된 부스추천시스템 성과와 계획되지 않은 행동에 대한 참관객의 만족도와 향후 부스추천시스템의 재사용의도간의 인과관계도 파악하고자 하였다. 이 때 부스추천시스템에대한신뢰는권한(competence), 자선(benevolence), 그리고진실(integrity)의2차요인(2nd order factor)으로구성하고, 나머지 요인들은 1차 요인으로 구성하였다. 이를 검증하기 위해 2011 DMC Culture Open 행사에서 부스추천시스템을 테스트하기 위하여 시스템을 개발하고, 101명의 참관객을 대상으로 실증조사를 하여 분석하였다. 분석결과 첫째, 부스추천시스템에 있어서 참관객의 신뢰가 가장 중요한 요소이며 실제 해당 부스추천시스템을 이용한 참관객들은 신뢰를 통해 부스추천시스템이 성과 있다고 인식하였다. 둘째, 참관객의 지식수준 역시 부스추천시스템의 성과에 유의한 영향을 미쳤는데 이는 추천의 성과가 전시장에 대한 사전적 이해가 필요함을 의미한다. 즉, 전시장에 대한 이해가 높은 참관객이 부스추천시스템의 유용성을 더 잘 파악하는 것으로 나타났다. 셋째, 기대된 개인화 수준은 성과에 유의한 영향을 미치지 못했는데 이는 기존 연구와 다른 결과로 본 연구에 사용된 부스추천시스템이 충분히 개인화 서비스를 제공하지 못했기 때문이라고 판단된다. 넷째, 부스추천시스템의 추천정보는 개인의 자유를 위협하거나 제한한다고 느끼지 않음으로 충분히 유용한 가치를 갖는다고 할 수 있다. 끝으로 부스정보시스템의 높은 성과는 참관객들의 계획되지 않은 행동에 대한 높은 만족도와 향후에도 부스추천시스템을 재사용할 의도를 만드는 것으로 나타났다. 이와 같이 본 연구는 부스추천시스템이 야기하는 참관객의 계획되지 않은 부스방문행동에 미치는 영향력을 분석하기 위해 계획되지 않은 행동이론을 중심으로 실증자료를 이용하여 분석하고, 이를 통해 향후 부스추천시스템의 구축 및 설계에 유용한 시사점을 도출할 수 있었다. 향후에는 보다 정교한 설문구성과 측정대상을 이용하여 추가적인 검토가 필요할 것으로 기대된다.

• Journal of Preventive Medicine and Public Health
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• 제20권1호
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• pp.165-203
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• 1987

This project was a service-cum-research effort with a quasi-experimental study design to examine the health benefits of an integrated Family Planning (FP)/Maternal & Child health (MCH) Service approach that provides crucial factors missing in the present on-going programs. The specific objectives were: 1) To test the effectiveness of trained nurse/midwives (MW) assigned as change agents in the Health Sub-Center (HSC) to bring about the changes in the eight FP/MCH indicators, namely; (i)FP/MCH contacts between field workers and their clients (ii) the use of effective FP methods, (iii) the inter-birth interval and/or open interval, (iv) prenatal care by medically qualified personnel, (v) medically supervised deliveries, (vi) the rate of induced abortion, (vii) maternal and infant morbidity, and (viii) preinatal & infant mortality. 2) To measure the integrative linkage (contacts) between MW & HSC workers and between HSC and clients. 3) To examine the organizational or administrative factors influencing integrative linkage between health workers. Study design; The above objectives called for quasi-experimental design setting up a study and control area with and without a midwife. An active intervention program (FP/MCH minimum 'package' program) was conducted for a 2 year period from June 1982-July 1984 in Seosan County and 'before and after' surveys were conducted to measure the change. Service input; This study was undertaken by the Soonchunhyang University in collaboration with WHO. After a baseline survery in 1981, trained nurses/midwives were introduced into two health sub-centers in a rural setting (Seosan county) for a 2 year period from 1982 to 1984. A major service input was the establishment of midwifery services in the existing health delivery system with emphasis on nurse/midwife's role as the link between health workers (nurse aids) and village health workers, and the referral of risk patients to the private physician (OBGY specialist). An evaluation survey was made in August 1984 to assess the effectiveness of this alternative integrated approach in the study areas in comparison with the control area which had normal government services. Method of evaluation; a. In this study, the primary objective was first to examine to what extent the FP/MCH package program brought about changes in the pre-determined eight indicators (outcome and impact measures) and the following relationship was first analyzed; b. Nevertheless, this project did not automatically accept the assumption that if two or more activities were integrated, the results would automatically be better than a non-integrated or categorical program. There is a need to assess the 'integration process' itself within the package program. The process of integration was measured in terms of interactive linkages, or the quantity & quality of contacts between workers & clients and among workers. Intergrative linkages were hypothesized to be influenced by organizational factors at the HSC clinic level including HSC goals, sltrurture, authority, leadership style, resources, and personal characteristics of HSC staff. The extent or degree of integration, as measured by the intensity of integrative linkages, was in turn presumed to influence programme performance. Thus as indicated diagrammatically below, organizational factors constituted the independent variables, integration as the intervening variable and programme performance with respect to family planning and health services as the dependent variable: Concerning organizational factors, however, due to the limited number of HSCs (2 in the study area and 3 in the control area), they were studied by participatory observation of an anthropologist who was independent of the project. In this observation, we examined whether the assumed integration process actually occurred or not. If not, what were the constraints in producing an effective integration process. Summary of Findings; A) Program effects and impact 1. Effects on FP use: During this 2 year action period, FP acceptance increased from 58% in 1981 to 78% in 1984 in both the study and control areas. This increase in both areas was mainly due to the new family planning campaign driven by the Government for the same study period. Therefore, there was no increment of FP acceptance rate due to additional input of MW to the on-going FP program. But in the study area, quality aspects of FP were somewhat improved, having a better continuation rate of IUDs & pills and more use of effective Contraceptive methods in comparison with the control area. 2. Effects of use of MCH services: Between the study and control areas, however, there was a significant difference in maternal and child health care. For example, the coverage of prenatal care was increased from 53% for 1981 birth cohort to 75% for 1984 birth cohort in the study area. In the control area, the same increased from 41% (1981) to 65% (1984). It is noteworthy that almost two thirds of the recent birth cohort received prenatal care even in the control area, indicating that there is a growing demand of MCH care as the size of family norm becomes smaller 3. There has been a substantive increase in delivery care by medical professions in the study area, with an annual increase rate of 10% due to midwives input in the study areas. The project had about two times greater effect on postnatal care (68% vs. 33%) at delivery care(45.2% vs. 26.1%). 4. The study area had better reproductive efficiency (wanted pregancies with FP practice & healthy live births survived by one year old) than the control area, especially among women under 30 (14.1% vs. 9.6%). The proportion of women who preferred the 1st trimester for their first prenatal care rose significantly in the study area as compared to the control area (24% vs 13%). B) Effects on Interactive Linkage 1. This project made a contribution in making several useful steps in the direction of service integration, namely; i) The health workers have become familiar with procedures on how to work together with each other (especially with a midwife) in carrying out their work in FP/MCH and, ii) The health workers have gotten a feeling of the usefulness of family health records (statistical integration) in identifying targets in their own work and their usefulness in caring for family health. 2. On the other hand, because of a lack of required organizational factors, complete linkage was not obtained as the project intended. i) In regards to the government health worker's activities in terms of home visiting there was not much difference between the study & control areas though the MW did more home visiting than Government health workers. ii) In assessing the service performance of MW & health workers, the midwives balanced their workload between 40% FP, 40% MCH & 20% other activities (mainly immunization). However, $85{\sim}90%$ of the services provided by the health workers were other than FP/MCH, mainly for immunizations such as the encephalitis campaign. In the control area, a similar pattern was observed. Over 75% of their service was other than FP/MCH. Therefore, the pattern shows the health workers are a long way from becoming multipurpose workers even though the government is pushing in this direction. 3. Villagers were much more likely to visit the health sub-center clinic in the study area than in the control area (58% vs.31%) and for more combined care (45% vs.23%). C) Organization factors (admistrative integrative issues) 1. When MW (new workers with higher qualification) were introduced to HSC, it was noted that there were conflicts between the existing HSC workers (Nurse aids with less qualification than MW) and the MW for the beginning period of the project. The cause of the conflict was studied by an anthropologist and it was pointed out that these functional integration problems stemmed from the structural inadequacies of the health subcenter organization as indicated below; i) There is still no general consensus about the objectives and goals of the project between the project staff and the existing health workers. ii) There is no formal linkage between the responsibility of each member's job in the health sub-center. iii) There is still little chance for midwives to play a catalytic role or to establish communicative networks between workers in order to link various knowledge and skills to provide better FP/MCH services in the health sub-center. 2. Based on the above findings the project recommended to the County Chief (who has power to control the administrative staff and the technical staff in his county) the following ; i) In order to solve the conflicts between the individual roles and functions in performing health care activities, there must be goals agreed upon by both. ii) The health sub·center must function as an autonomous organization to undertake the integration health project. In order to do that, it is necessary to support administrative considerations, and to establish a communication system for supervision and to control of the health sub-centers. iii) The administrative organization, tentatively, must be organized to bind the health worker's midwive's and director's jobs by an organic relationship in order to achieve the integrative system under the leadership of health sub-center director. After submitting this observation report, there has been better understanding from frequent meetings & communication between HW/MW in FP/MCH work as the program developed. Lessons learned from the Seosan Project (on issues of FP/MCH integration in Korea); 1) A majority or about 80% of the couples are now practicing FP. As indicated by the study, there is a growing demand from clients for the health system to provide more MCH services than FP in order to maintain the achieved small size of family through FP practice. It is fortunate to see that the government is now formulating a MCH policy for the year 2,000 and revising MCH laws and regulations to emphasize more MCH care for achieving a small size family through family planning practice. 2) Goal consensus in FP/MCH shouBd be made among the health workers It administrators, especially to emphasize the need of care of 'wanted' child. But there is a long way to go to realize the 'real' integration of FP into MCH in Korea, unless there is a structural integration FP/MCH because a categorical FP is still first priority to reduce the rate of population growth for economic reasons but not yet for health/welfare reasons in practice. 3) There should be more financial allocation: (i) a midwife should be made available to help to promote the MCH program and coordinate services, (in) there should be a health sub·center director who can provide leadership training for managing the integrated program. There is a need for 'organizational support', if the decision of integration is made to obtain benefit from both FP & MCH. In other words, costs should be paid equally to both FP/MCH. The integration slogan itself, without the commitment of paying such costs, is powerless to advocate it. 4) Need of management training for middle level health personnel is more acute as the Government has already constructed 90 MCH centers attached to the County Health Center but without adequate manpower, facilities, and guidelines for integrating the work of both FP and MCH. 5) The local government still considers these MCH centers only as delivery centers to take care only of those visiting maternity cases. The MCH center should be a center for the managment of all pregnancies occurring in the community and the promotion of FP with a systematic and effective linkage of resources available in the county such as i.e. Village Health Worker, Community Health Practitioner, Health Sub-center Physicians & Health workers, Doctors and Midwives in MCH center, OBGY Specialists in clinics & hospitals as practiced by the Seosan project at primary health care level.