B y t V khoa hc v o to

Khoa hc hnh vi v gio dc sc kho

Sch dng o to C nhn y t cng cng M s: 14Z05

Nh xut bn y hc H ni - 2005

Ch bin

PGS.TS. Nguyn Th Thu

Nhng ngi bin son

ThS. Nguyn Thu Anh

Tham gia t chc bn tho

PGS.TS. Nguyn Th Thu PGS.TS. Nguyn Th Bch Lin PGS.TS. Phng Vn Hon TS. Trn Nh Nguyn TS. Khng Vn Duy TS. L Trn Ngoan ThS. ng Huy Hong ThS. Nguyn Thu Anh

Bn quyn thuc B Y t (V khoa hc v o to)

LI GII THIU

Thc hin Ngh nh 43/2000/N -CP ngy 30/8/2000 ca Chnh Ph quy nh chi tit v hng dn trin khai Lut Gio dc, B Y t ph duyt ban hnh cc chng trnh khung cho Gio dc i hc nhm ngnh Y t cng cng (YTCC). B Y t t chc bin son b ti liu dy -hc cc mn hc c s v chuyn ngnh theo chng trnh mi nhm tng bc xy dng b sch chun trong cng tc o to i hc chuyn ngnh YTCC ca ngnh Y t. Trn c s sch Khoa hc hnh vi v Gio dc sc khe c t chc bin son li da trn gio trnh Nng cao sc khe (NCSK) s dng ging dy cho i tng C nhn YTCC t nm 2002, vi s tham gia bin son ca cc Ging vin B mn Gio dc sc khe (GDSK) v cc ging vin kim chc ca trng i hc YTCC. Thi gian trc y, tp gio trnh GDSK v NCSK c bin son c ni dung tp trung cp n qu trnh GDSK nhm nng cao kin thc, thay i thi v hnh vi ca i tng theo hng tch cc, c li cho sc khe. Thc t hnh thnh, duy tr bn vng hnh vi sc khe lnh mnh, iu m chng ta mong mun, khng th t c nu ch n thun thc hin GDSK. Qu trnh ny phi din ra v tch hp trong nhng mi trng thun li, vi nhng chnh sch thch hp, ng thi cc c nhn tham gia phi c nhng k nng cn thit. iu ny c ch ra trong cc chin lc hnh ng chnh ca Hin chng Ottawa v NCSK nm 1986 gp phn t c mong mun Sc khe cho mi ngi. cp nht nht kin thc v NCSK cho sinh vin YTCC, cc tc gi cu trc li ni dung cun sch vi ba phn chnh: nhng ni dung c bn ca NCSK, nhng k nng chnh trong NCSK v trin khai cc chng trnh NCSK ti cng ng. Trong ni dung truyn thng, GDSK vn c th hin l mt cu phn quan trng ca chng trnh NCSK. Nhng l thuyt v hnh vi c trnh by vi mc ch gip cc cn b s v ang hot ng trong lnh vc YTCC c th ng dng phn tch, gii thch v d on hnh vi c nhn gp phn xy dng cc chin lc can thip NCSK hiu qu. Sch c Hi ng chuyn mn thm nh sch gio khoa v ti liu dy hc ca B Y t ph chun xut bn lm ti liu Dy-Hc chnh thc cho i tng C nhn YTCC trong giai on hin nay, ng thi c th s dng tham kho cho cc i tng khc ang hc tp v cng tc trong ngnh YTCC. Sau mt thi gian th nghim, sch cn c hiu chnh tiu , b sung v cp nht ni dung ph hp vi yu cu, tnh hnh mi. V Khoa hc v o to, B y t xin chn thnh cm n Trng i hc YTCC bin son cun sch ny. Chng ti mong nhn c kin ng gp ca cc ng nghip, ging vin v sinh vin cun sch ngy cng hon thin hn.

B Y T V KHOA HC v O TO
3

MC LC

Phn 1. GII THIU V NNG CAO SC KHO 1. Sc kho v chm sc sc kho ban u 2. Gio dc sc kho 3. Nng cao sc kho 4. Cc nguyn tc chnh ca nng cao sc kho Cu hi tho lun Hnh vi sc kho v qu trnh thay i hnh vi 1. Nhng yu t quyt nh sc kho 2. Hnh vi sc kho v nhng yu t nh hng 3. Qu trnh thay i hnh vi sc kho 4. Qu trnh thay i hnh vi v can thip thch hp Cu hi tho lun Cc phng thc tip cn v m hnh nng cao sc kho 1. Cc phng thc tip cn nng cao sc kho 2. Cc m hnh nng cao sc kho Cu hi tho lun Phng php truyn thng sc kho 1. Qu trnh truyn thng 2. Phng tin truyn thng 5. Tip cn truyn thng-gio dc sc kho 6. Cc phng php truyn thng i chng 7. Nhng k nng giao tip Cu hi tho lun ng gi nhu cu sc kho 1. Khi nim nhu cu sc kho 2. Cc dng nhu cu 3. Cc bc thc hin nh gi nhu cu sc kho 4. Phng php thu thp thng tin 4 9 9 11 14 22 23 24 24 27 35 39 44 46 46 53 60 62 62 71 79 84 86 87 88 88 89 90 96

Bi tp thc hnh Lp k hoch chng trnh nng cao sc kho 1. Khi nim v mc ch, mc tiu 2. Cc yu cu ca mc tiu 3. La chn chin lc/gii php thch hp 4. Pht trin cc hot ng c th theo cc gii php 5. Xc nh ngun lc thc hin chng trnh Bi tp thc hnh: ng gi chng trnh nng cao sc kho 1. Khi nim, mc ch nh gi 2. Cc loi hnh nh gi 3. Phng php nh gi 4. Chun b nh gi Bi tp thc hnh Phn 3. Pht trin cng ng trong nng cao sc kho 1. Khi nim cng ng trong nng cao sc kho 2. Cc quan im nh hng pht trin cng ng 3. Cch tip cn pht trin cng ng 4. Cc dng hot ng trong pht trin cng ng 5. S tham gia ca cng ng 6. Pht trin cng ng v kh khn trong thc tin Cc cu hi tho lun Nng cao sc kho mt s c s Phn 1. Nng cao sc kho trong trng hc 1. V tr v tm quan trng ca y t trng hc 2. Ni dung chnh ca y t trng hc 3. Nhim v ca nhn vin y t ti trng hc 4. Mi nghip v qun l y t trng hc Nng cao sc kho ti ni lm vic

97 98 98 103 104 105 106 107 108 108 110 114 115

5. Cc bc nh gi chng trnh gio dc sc kho, nng cao sc kho 115 116 119 119 121 122 123 124 126 128 128 129 130 134 134

DANH MC CH VIT TT

CBYT CSSKBD GD-NCSK GDSK HIV/AIDS NCSK PTC PTTTC SDD STD TTC TT-GDSK UNICEF WHO YTCC

Cn b y t Chm sc sc khe ban u Gio dc - Nng cao sc khe Gio dc sc khe Virus gy suy gim min dch ngi/Hi chng suy gim min dch mc phi Nng cao sc khe Pht trin cng ng Phng tin truyn thng i chng Suy dinh dng Bnh ly truyn qua ng tnh dc (Sexual Transmitted Diseases) Truyn thng i chng Truyn thng - Gio dc sc khe Qu Nhi ng Lin hip quc T chc Y t Th gii Y t cng cng

Phn 1

Nhng ni dung c bn ca Nng cao sc kho

Bi 1

GII THIU V NNG CAO SC KHO

MC TIU
1. Nu c cc khi nim v Sc khe, Gio dc sc khe v Nng cao sc khe. 2. Trnh by c qu trnh pht trin ca Gio dc sc khe v Nng cao sc khe. 3. Trnh by c cc nguyn tc chnh ca Nng cao sc khe. 4. Trnh by c nhng chin lc hnh ng chnh ca Nng cao sc khe

cc nc ang pht trin.

1. SC KHE V CHM SC SC KHE BAN U

Ngay t khi hnh thnh cuc sng ca con ngi, sc khe tr thnh mt ch quan tm chnh ca nhn loi. Nhiu y vn trc y cp s chng chi vi bnh tt ca con ngi v miu t nhng yu t tc ng c hi vi sc khe cng nh cc yu t gip cho con ngi khe mnh v ko di cuc sng. Ngy nay con ngi c nhiu kin thc v phng tin phng nga v kim sot bnh tt. Nhiu ngi bit cch phng bnh, bo v sc khe cho c nhn, cho gia nh v cho c cng ng. Nhng thc t kin thc v k nng v sc khe, chm sc sc khe, cc ngun lc cn thit cn nhiu khc bit gia cc c nhn, cc cng ng. Gn y, khoa hc y hc c nhng tin b vt bc. Chng ta hiu bit ton din hn, su hn v cc yu t nguy c ca bnh tt, cc thng tin dch t v tnh hnh bnh tt, au m, cht non cc nhm dn c khc nhau trong cng ng. Thc t cng cho chng ta thy rng s ci thin r rt v sc khe kh c th t c nu thiu s ci thin cc iu kin kinh t v x hi. Ngho i, iu kin sng thiu thn, hn ch v hc hnh, thiu cc thng tin, kin thc v sc khe l cc tr ngi chnh cho ngi dn c c tnh trng sc khe mong mun. Chng ta cng hiu su sc hn v s bt cng bng trong chm sc sc khe v cc gii php tng bc ci thin vn ny. T chc Y t Th gii (WHO) c thnh lp vo nm 1946, vi mong mun em li sc khe tt nht cho tt c mi ngi. WHO nh ngha: Sc khe l tnh trng hon ton thoi mi v th cht, tm thn, v x hi ch khng ch l khng c bnh tt hoc au yu. Mc d bn cht ca cc vn sc khe, m hnh bnh tt c nhiu thay i, nhng mc ch trng tm v mong mun em li tnh trng sc khe tt cho mi ngi ca T chc ny khng h thay i. Tnh trng sc kho tt c hm l con ngi t c s cn bng ng vi mi trng xung quanh, c kh nng thch ng vi mi trng. i vi c nhn, tnh trng sc kho tt c ngha l cht lng cuc sng ca h c ci thin, t b au m, t khuyt tt; cuc sng c nhn, gia nh v x hi hnh phc; c nhn c c hi 9

lc chn trong cng vic v ngh ngi. i vi cng ng, c tnh trng sc kho tt c ngha l cht lng cuc sng ca ngi dn cao hn; ngi dn c kh nng tham gia tt hn trong vic lp k hoch v thc hin cc hot ng phng bnh, hoch nh chnh sch v sc kho. Nm 1978, WHO v Qu Nhi ng Lin hp quc (UNICEF) t chc Hi ngh quc t v Chm sc sc khe ban u (CSSKB) ti Alma-Ata (Kazakstan). Hi ngh nht tr thng qua mt tuyn b lch s: "Sc khe cho mi ngi c th t c bng cch s dng y v hiu qu cc ngun lc ca th gii...". Mc ch m WHO v cc quc gia theo ui l "Sc khe cho mi ngi n nm 2000". Cc quc gia cng nhn thy rng CSSKB chnh l bin php t c mc ch ny. y l qu trnh chm sc mc tip xc u tin, gn nht ca cc c nhn, gia nh v cng ng vi h thng y t nh nc, nhm p ng nhng nhu cu y t thit yu cho s ng ngi, vi chi ph thp nht, to thnh bc u tin trong qu trnh chm sc sc khe lin tc. y l cng vic ca cc nhn vin y t, cc trm y t, cc trung tm y t, cc bnh vin, cc phng khm a khoa khu vc. Hot ng CSSKB cn gm c nhng hot ng t chm sc sc khe ca cc h gia nh. CSSKB c xem nh l mt chin lc quan trng ngi dn trn ton th gii c c tnh trng sc khe cho php h sng mt cuc sng hnh phc. CSSKB a ra nhng tip cn mi, c tnh thc hnh cho cc nc v ang pht trin hnh ng hng n mc ch sc khe cho mi ngi. CSSKB tp trung gii quyt tm ch chnh:
1. Gio dc v cc vn sc khe ph bin, cng nh cc phng php

phng nga v kim sot chng.

2. Cung cp y nc sch v cc vn v sinh c bn. 3. Tng cng vic cung cp thc phm v dinh dng hp l. 4. Tim chng phng cc bnh ly nhim chnh. 5. Chm sc sc khe b m, tr em, bao gm c k hoch ha gia nh. 6. iu tr thch hp cc bnh thng thng v chn thng. 7. Phng v kim sot cc bnh dch ti a phng. 8. m bo thuc thit yu.

Vit Nam b sung thm hai ch quan trng na trong thc t chin lc hot ng ca quc gia, l:
9. Cng c mng li y t c s v 10. Tng cng cng tc qun l sc kho tuyn c s.

Tip cn CSSKB cc nc v ang pht trin c nhng mc tiu sau: To iu kin cho ngi dn c th tm kim dch v chm sc sc khe ti nh, trong trng hc, trong nh my, ti ni lm vic. To iu kin cho ngi dn phng nga bnh tt v chn thng c th phng trnh c. 10

 To iu kin cho ngi dn thc hin quyn v ngha v ca mnh trong vic xy dng mi trng thun li c mt cuc sng khe mnh. To iu kin cho ngi dn tham gia v thc hin vic lp k hoch qun l sc khe, m bo chc chn nhng iu kin tin quyt cho sc khe. WHO xc nh cc hot ng hng n sc khe cho mi ngi phi da vo bn lnh vc hot ng chnh, l: Nhng cam kt chnh tr, x hi v s quyt tm t c sc khe cho mi ngi nh mt mc tiu x hi chnh cho nhng thp k ti. S tham gia ca cng ng, tham gia ca ngi dn v huy ng cc ngun lc x hi cho s pht trin y t. Hp tc gia cc lnh vc khc nhau nh nng nghip, gio dc, truyn thng, cng nghip, nng lng, giao thng vn ti, nh ... H thng h tr m bo rng mi ngi c th tip cn dch v chm sc sc khe thit yu, thng tin khoa hc, cng ngh y t thch hp.
2. GIO DC SC KHO 2.1. Khi nim

Sc khe ca mt cng ng ch c th c nng cao khi ngi dn trong cng ng hiu bit v cch phng nga bnh tt, ch ng tham gia vo vic phng nga v kim sot bnh, ng gp kin gii quyt cc vn lin quan n sc khe ca chnh h, cng nh cc hot ng chm sc sc khe. Nhng hot ng nhm cung cp cho ngi dn kin thc, k nng phng nga bnh tt, bo v sc khe cho chnh h v cng ng xung quanh chnh l nhng hot ng truyn thng sc khe gio dc sc khe (GDSK). Trong mi ni dung v CSSKB th ni dung GDSK c xp hng u, iu ny cho chng ta thy vai tr ca GDSK rt quan trng. Cho n gia thp k 80, thut ng "Gio dc sc khe" c s dng mt cch rng ri m t cng vic ca nhng ngi lm cng tc thc hnh nh y t, bc s. Ngi dn thng la chn cch chm sc sc khe ph hp cho chnh mnh nn c th cung cp thng tin cho h v cch phng bnh, khuyn khch h thay i hnh vi khng lnh mnh, trang b cho h nhng kin thc v k nng c c cuc sng khe mnh thng qua hot ng gio dc sc khe nh t vn, thuyt phc v truyn thng i chng. Mt trong nhng kh khn thng gp phi trong GDSK l quyn t do la chn thng tin v mc t nguyn thc hin ca ngi dn. Nu ngi dn khng nhn thc ng, khng t nguyn lm theo hng dn, m h li la chn, quyt nh thc hin nhng hnh vi c hi cho sc khe th d ngi lm cng tc GDSK, cc nhn vin y t c xc nh ng nhu cu ca ngi dn, quyt nh cch thc, thi im can thip ph hp, s dng nhng phng tin truyn thng hiu qu, h c c gng m bo s hi lng ca ngi dn n mc no i chng na th kt qu ca nhng hot ng GDSK vn rt thp. 11

Khi xem xt GDSK trn phng din thc hnh, chng ta c th ngh rng GDSK l s cung cp thng tin v n s thnh cng trong vic tng cng sc khe khi i tng lm theo li khuyn ca chng ta. Nhng i vi mt s nh GDSK khc th gio dc l mt phng tin ca s "tm hiu" i tng. Ngi dn khng phi l mt chic bnh rng ta s y thng tin lin quan, li khuyn, hng dn thay i hnh vi ca h. Chng ta bit, thng tin v nguy c ca vic ht thuc l c bit n t nm 1963, thng tin v ly nhim HIV/AIDS c bit t nm 1986 nhng c mt t l ng k ngi dn vn tip tc ht thuc v quan h tnh dc khng an ton. Nhng nh GDSK ny cho rng khng d dng thuyt phc c ngi dn v cng khng th p buc c h v iu ny c th khng nhng khng t c hiu qu, m cn c th nh hng n kha cnh o c. Ngi GDSK phi l ngi tr gip, to iu kin thun li cho ngi dn thc hin hnh vi lnh mnh. Ngoi vic yu cu ngi dn phi lm nhng g, ngi GDSK phi cng lm vic vi ngi dn tm hiu nhu cu ca h, v cng hnh ng hng n s la chn cc hnh vi lnh mnh trn c s hiu bit y v nhng hnh vi c hi cho sc khe. Green v cng s (1980) nh ngha GDSK l s tng hp cc kinh nghim nhm to iu kin thun li ngi dn chp nhn mt cch t nguyn cc hnh vi c li cho sc khe. Khi nim GDSK c cp trong ti liu K nng ging dy v Truyn thng - Gio dc sc khe ca B Y t (1994) l mt qu trnh nhm gip ngi dn tng cng hiu bit thay i thi , t nguyn thay i nhng hnh vi c hi cho sc khe, chp nhn v duy tr thc hin nhng hnh vi lnh mnh, c li cho sc khe.
2.2. Lm th no gip cho mi ngi sng khe mnh hn?

C mt s cch tip cn thng gp nhm gip mi ngi sng khe mnh hn: Cung cp thng tin, gii thch, khuyn bo, hy vng mi ngi s tip thu v p dng ci thin tnh trng sc khe. C th gp g tng ngi lng nghe, trao i v cc vn lin quan n sc khe, gi cho h quan tm hoc tham gia vo gii quyt cc vn ca chnh h. p buc mi ngi thay i v cng ch nu khng thay i hnh vi c hi cho sc khe ca h. gip ngi dn sng khe mnh hn mt cch hiu qu, cc nhn vin, cn b y t cng cng c th thc hin cng tc GDSK bng nhiu cch: Ni chuyn vi mi ngi v lng nghe nhng vn v mong mun ca h. Xc nh cc hnh vi hay nhng hnh ng tiu cc c th xy ra ca ngi dn, gii quyt v ngn chn nhng hnh vi bt li i vi sc khe. Cng ngi dn tm hiu cc yu t nh hng, nguyn nhn dn n nhng hnh ng ca ngi dn, nhng vn h cha gii quyt c gy ra hnh vi ca ngi dn. ng vin mi ngi la chn cch gii quyt vn ph hp vi hon cnh ca h. 12

 ngh ngi dn a ra cch gii quyt vn ca h. H tr, cung cp thng tin, phng tin, cng c cho ngi dn h c th nhn thc, la chn v p dng gii quyt thch hp vi chnh h.
2.3. Bn cht ca gio dc sc kho

GDSK l mt phn chnh, quan trng ca nng cao sc khe (NCSK) ni ring cng nh ca cng tc chm sc sc khe ni chung. GDSK nhm hnh thnh v thc y nhng hnh vi lnh mnh. Hnh vi ca con ngi c th l nguyn nhn chnh gy ra mt vn sc khe. V d nghin ht thuc l c th gy ra ung th phi. Tc ng i tng khng ht thuc hoc cai thuc l trong trng hp ny l gii php chnh. Bng cch thay i hnh vi, chng ta c th ngn nga hoc gii quyt c vn ca h. Thng qua GDSK chng ta gip mi ngi hiu r hnh vi ca h, bit c hnh vi ca h tc ng, nh hng n sc khe ca h nh th no. Chng ta ng vin mi ngi t la chn mt cuc sng lnh mnh, ch khng c tnh p buc thay i. GDSK khng thay th c cc dch v y t khc, nhng n rt cn thit y mnh vic s dng ng cc dch v ny. Tim chng l mt minh ha r nt: nu nhiu ngi khng hiu r v khng tham gia tim chng th nhng thnh tu v vaccin s chng c ngha g; thng rc cng cng s v ch tr phi mi ngi u c thi quen b rc vo . GDSK khuyn khch nhng hnh vi lnh mnh, lm sc khe tt ln, phng nga m au, chm sc v phc hi sc khe. i tng ca cc chng trnh GDSK chnh l nhng c nhn, nhng gia nh, nhng nhm ngi, t chc v nhng cng ng khc nhau. Tuy nhin, nu ch c GDSK nhm thay i hnh vi ca ngi dn th cha v hnh vi ca con ngi c lin quan vi nhiu yu t. Chnh v th, hnh vi sc khe ca ngi dn thay i, duy tr v bn vng th chng ta phi c nhng chin lc tc ng n cc yu t khc nh hng n hnh vi nh: cc ngun lc sn c, s ng h ca nhng ngi ra quyt nh, ngi hoch nh chnh sch, mi trng t nhin v x hi... v y chnh l hot ng ca lnh vc NCSK. Hnh vi sc khe c hiu nh th no? Yu t c th no nh hng n hnh vi? Khi nim v ni dung ca NCSK v cc hot ng ca qu trnh ny s c xem xt y trong nhng bi tip theo.
2.4. Ngi lm cng tc gio dc sc kho

C mt s ngi c o to chuyn lm cng tc GDSK, h c coi l nhng chuyn gia v lnh vc ny. Cng vic ca cc cn b chuyn mn khc nh: bc s, iu dng, h sinh, gio vin, hun luyn vin... u t nhiu c lin quan n vic cung cp thng tin, tuyn truyn, hng dn, gip ngi dn tng cng, nng cao kin thc v k nng v phng bnh, bo v, chm sc sc khe, v th h u tham gia lm GDSK. Chng ta c th ni rng GDSK l nhim v ca bt c ngi no tham gia vo cc hot ng y t v pht trin cng ng (PTC). lm tt cng tc GDSK, ngi lm cng tc ny cn rn luyn k nng truyn thng, k nng giao tip, k nng tip cn ngi dn, cng ng.

13

3. NNG CAO SC KHE 3.1. Lch s v khi nim nng cao sc kho

Sc khe ca chng ta chu s tc ng ca nhiu yu t nh: yu t c nhn, yu t mi trng ni chung, yu t cht lng ca dch v chm sc, bo v sc khe. Nh vy, ngoi vic GDSK tc ng n tng c nhn, cc nhm ngi hoc nhng cng ng ln hn, chng ta cn phi tc ng thay i, ci thin mi trng ni chung, cng nh cht lng ca dch v chm sc sc khe theo chiu hng tch cc, c li cho sc khe. Cng vic mang tnh cht a dng ny lin quan n nhiu lnh vc, ngnh khc nhau. Cch tip cn mang tnh ton din, a ngnh nhm to iu kin d dng cho nhng hot ng GDSK, chm sc sc khe cui cng con ngi c c cuc sng khe mnh, tnh trng sc khe tt. Nhng cng vic, hot ng c tnh cht a dng, phc tp va nu trn c gi l nhng hot ng NCSK. Trong hot ng NCSK, ngoi vic cc chuyn gia, cn b chuyn mn y t xc nh nhng vn sc khe, bn thn ngi dn cn t xc nh nhng vn sc khe lin quan n h trong cng ng. Ngoi nhng cn b y t, gio vin, nh qun l, cc cn b x hi u c th tham gia vo cng tc NCSK. Ngi dn c sc khe tt c xem nh l trch nhim chung ca ton x hi. Vo cui nhng nm 80, cc Hi ngh quc t v NCSK xc nh cc chin lc hnh ng tng cng tin trnh hng n mc tiu "Sc khe cho mi ngi", iu m trong tuyn ngn Alma Ata nm 1978 nu ra. Nm 1986, Hi ngh quc t u tin v NCSK ca cc nc pht trin, c t chc ti Ottawa, Canada. Khi nim v NCSK c nu ra l qu trnh nhm to iu kin thun li, gip ngi dn tng kh nng kim sot v ci thin sc khe ca h; l mt s cam kt gii quyt nhng thch thc nhm lm gim s bt cng bng v chm sc sc khe; m rng phm vi d phng, gip ngi dn i ph vi hon cnh ca h; to ra mi trng c li cho sc khe trong ngi dn c kh nng t chm sc cho bn thn h mt cch tt hn". Hi ngh a ra bn Hin chng v NCSK trong ch r nm lnh vc hnh ng c coi nh nhng chin lc chnh trin khai cc chng trnh can thip nhm ci thin tnh trng sc kho ca ngi dn, nng cao cht lng cuc sng, l:
1. Xy dng chnh sch cng cng v sc khe. 2. To ra nhng mi trng h tr. 3. Huy ng s tham gia v y mnh hnh ng cng ng. 4. Pht trin nhng k nng c nhn v 5. nh hng li cc dch v sc khe hng v d phng v NCSK.

Cc thnh vin tham d Hi ngh thng nht quan im vn ng to ra s cam kt chnh tr cho sc khe v cng bng trong tt c cc lnh vc lin quan, p ng nhng nhu cu sc khe cc quc gia khc nhau, khc phc s bt cng bng 14

trong chm sc sc khe, v nhn thc rng sc khe v vic duy tr sc khe i hi phi u t ngun lc ng k v cng l mt thch thc ln ca x hi. WHO cng xc nh v nhn mnh n vic ci thin hnh vi, li sng, nhng iu kin v mi trng v chm sc sc khe s c hiu qu thp nu nhng iu kin tin quyt cho sc kho nh: ha bnh; nh ; lng thc, thc phm; nc sch; hc hnh; thu nhp; h sinh thi n nh; c hi bnh ng v cng bng x hi khng c p ng mt cch c bn (Hin chng Ottawa 1986). Hai nm sau (1988), Hi ngh quc t ln th hai v NCSK ca cc nc cng nghip ha c t chc ti Adelaide, Australia, tp trung vo lnh vc u tin trong nm lnh vc hnh ng, l xy dng chnh sch cng cng v sc khe. Cng trong nm ny, mt hi ngh gia k xem xt li tin trnh thc hin cc hot ng hng n sc khe cho mi ngi vo nm 2000, c t chc ti Riga, Lin X c. Hi ngh ny ngh cc nc i mi v y mnh nhng chin lc CSSKB, tng cng cc hnh ng x hi v chnh tr cho sc khe, pht trin v huy ng nng lc lnh o, trao quyn cho ngi dn v to ra mi quan h cng tc cht ch trong cc c quan, t chc hng ti sc khe cho mi ngi. ng thi nhng ch ny phi c ch ra trong k hoch hnh ng ca chng trnh NCSK. Nhng iu kin mang tnh t ph v thch thc ny cng m ra nhng c hi cho cc nc ang pht trin y mnh cc chin lc NCSK v nhng hnh ng h tr t c mc ch sc khe cho mi ngi v s pht trin kinh t x hi. Nm 1989, mt nhm chuyn gia v NCSK ca cc nc ang pht trin hp ti Geneva, Thy S a ra mt vn kin chin lc gi l: "Li ku gi hnh ng". Ti liu ny xem xt phm vi v hot ng thc t ca NCSK cc nc ang pht trin. Ni dung chnh bao gm: khi ng nhng hnh ng x hi, chnh tr cho sc khe; duy tr, cng c nhng chnh sch chung y mnh hot ng y t, v xy dng nhng mi quan h tt gia cc c quan, t chc x hi; xc nh cc chin lc trao quyn lm ch cho ngi dn, v tng cng nng lc ca quc gia v nhng cam kt chnh tr cho NCSK v pht trin cng ng trong s pht trin y t ni chung. Li ku gi hnh ng cng thc hin vai tr ca NCSK trong vic to ra v tng cng cc iu kin ng vin ngi dn c nhng la chn vic chm sc sc khe ng n v cho php h sng mt cuc sng khe mnh. Vn kin ny nhn mnh vic "vn ng nh l mt phng tin ban u cho c vic to ra v duy tr nhng cam kt chnh tr cn thit t c nhng chnh sch thch hp cho sc khe i vi tt c cc lnh vc v pht trin mnh m cc mi lin kt trong chnh ph, gia cc chnh ph v cng ng ni chung. Vo nm 1991, Hi ngh quc t ln th ba v NCSK c t chc ti Sundsvall, Thy in. Hi ngh lm r lnh vc hnh ng th hai trong nm lnh vc hnh ng xc nh ti Hi ngh ln u tin Ottawa, l to ra nhng mi trng h tr. Thut ng "mi trng" c xem xt theo ngha rng ca n, bao hm mi trng x hi, chnh tr, kinh t, vn ha, cng nh mi trng t nhin. 15

Hi ngh quc t ln th t v NCSK t chc vo nm 1997 ti Jakarta, Indonesia pht trin nhng chin lc cho sc khe mang tnh quc t. Sc khe tip tc c nhn mnh l quyn c bn ca con ngi v l yu t tin quyt cho s pht trin kinh t v x hi. NCSK c nhn thc l mt thnh phn thit yu ca qu trnh pht trin sc khe. Cc iu kin tin quyt cho sc khe tip tc c nhn mnh c b sung thm s tn trng quyn con ngi, v xc nh ngho i l mi e da ln nht n sc khe. Nm lnh vc hnh ng trong Hin chng Ottawa vn c xem nh nm chin lc c bn ca NCSK v ph hp vi tt c cc quc gia. Hi ngh cng xc nh nhng u tin cho NCSK trong th k 21, l: y mnh trch nhim x hi i vi sc khe. Tng u t cho sc khe. on kt v m rng mi quan h i tc v sc khe. Tng cng nng lc cho cng ng v trao quyn cho c nhn. m bo c s h tng cho NCSK. Nm 2000, ti Mexico City, Hi ngh quc t ln th nm v NCSK din ra vi khu hiu "Thu hp s bt cng bng. i din B Y t ca 87 quc gia k Tuyn b chung v nhng ni dung chin lc cho NCSK. Hi ngh quc t ln th su v NCSK va din ra thng 8 nm 2005 ti Bangkok, Thi Lan xc nh nhng chin lc v cc cam kt v NCSK gii quyt cc yu t quyt nh sc khe trong xu th ton cu ha. Hin chng ca Hi ngh c pht trin da trn cc nguyn tc, chin lc hnh ng chnh ca Hin chng Ottawa. NCSK mt ln na c nhn mnh l qu trnh nhm to iu kin thun li, gip ngi dn tng kh nng kim sot sc khe v cc yu t quyt nh sc khe ca h v bng cch ci thin sc khe ca ngi dn. Nhng chin lc chnh cho NCSK trong xu th ton cu ha c ch ra l: Vn ng cho sc khe da trn quyn con ngi v s on kt. u t vo nhng chnh sch bn vng, cc hnh ng v c s h tng gii quyt cc yu t quyt nh sc khe. Xy dng nng lc pht trin chnh sch, lnh o, thc hnh NCSK, chuyn giao kin thc v nghin cu. Qui nh v lut php m bo mc bo v cao nht, trnh s e da ca nhng mi nguy hi v cho php c hi sc khe bnh ng i vi mi ngi. Mi quan h i tc v xy dng nhng lin minh vi cng chng, cc t chc t nhn, cc t chc phi chnh ph v cc lc lng x hi khc duy tr bn vng nhng hnh ng v sc khe. Nhng cam kt v sc khe cho mi ngi cng c nu r: 16

 Lm cho NCSK tr thnh vn trung tm trong chng trnh ngh s pht trin ton cu. Lm cho NCSK l trch nhim chnh ca tt c cc chnh ph. Lm cho NCSK l mt vn trng tm ca cc cng ng, x hi. Thit lp v thc hin quan h cng tc hiu qu trong cc chng trnh NCSK.
3.2. nh ngha v nng cao sc kho

NCSK l mt thut ng c hm rng, th hin mt qu trnh x hi v chnh tr ton din, khng ch gm nhng hnh ng hng trc tip vo tng cng nhng k nng v nng lc ca cc c nhn m cn hnh ng gim nh cc tc ng tiu cc ca cc vn x hi, mi trng v kinh t i vi sc khe. So vi GDSK, NCSK c ni dung rng hn, khi qut hn. NCSK kt hp cht ch tt c nhng gii php c thit k mt cch cn thn tng cng sc khe v kim sot bnh tt. Mt c trng chnh ni bt ca NCSK l tm quan trng ca "chnh sch cng cng cho sc khe" vi nhng tim nng ca n t c s chuyn bin x hi thng qua lut php, ti chnh, kinh t, v nhng hnh thi khc ca mi trng chung (Tones 1990). NCSK c th c phn bit r hn so vi GDSK l cc hot ng ca n lin quan n cc hnh ng chnh tr v mi trng. Cc tc gi Green v Kreuter (1991) nh ngha NCSK l "Bt k mt s kt hp no gia GDSK v cc yu t lin quan n mi trng, kinh t v t chc h tr cho hnh vi c li cho sc khe ca cc c nhn, nhm hoc cng ng". V th NCSK khng phi ch l trch nhim ca ring ngnh y t, m l mt lnh vc hot ng mang tnh cht lng ghp, a ngnh hng n mt li sng lnh mnh t c mt trng thi khe mnh theo ng ngha ca n. Nu da vo nh ngha trn th GDSK l mt b phn quan trng ca NCSK nhm to ra, thc y v duy tr nhng hnh vi c li cho sc khe. Thut ng NCSK thng c dng nhn mnh nhng n lc nhm gy nh hng n hnh vi sc khe trong mt khung cnh x hi rng hn. NCSK v GDSK c mi lin kt cht ch vi nhau. Trong thc t, qu trnh GDSK thng i t ngi GDSK n ngi dn, cn trong qu trnh NCSK ngi dn tham gia vo qu trnh thc hin. n nay, khi nim v NCSK a ra trong Hin chng Ottawa v vn ang c s dng rng ri: "NCSK l qu trnh nhm to iu kin thun li, gip ngi dn tng kh nng kim sot v ci thin sc khe ca h". WHO xc nh c 3 cch nhng ngi lm cng tc NCSK c th ci thin tnh hnh sc khe thng qua vic lm ca h, l: vn ng c c s ng h, chnh sch h tr; to ra nhng iu kin thun li; v iu tit cc hot ng. Cho n nay, NCSK c hiu nh l mt qu trnh ca s ci thin sc khe cho c nhn, nhm hoc cng ng. WHO xc nh l s trao quyn lm ch, to s cng bng, cng tc v s tham gia ca cc bn c lin quan. Nhng gi tr ny nn c kt hp cht ch trong mi hot ng v sc khe v cng tc ci thin i sng. NCSK v th l mt cch tip cn lng ghp xc nh v thc hin nhng cng tc y t.

17

3.3. Nng cao sc kho cc nc ang pht trin 3.3.1. T khi nim n hnh ng

NCSK l hng hot ng x hi cho s pht trin sc khe. N l mt khi nim lm hi sinh cch tip cn CSSKB ti c cc nc ang pht trin v cc nc cng nghip. NCSK v hnh ng ca x hi v mc ch sc khe cho mi ngi bng hai cch: tng cng li sng lnh mnh v cng ng hnh ng v sc khe; to ra nhng iu kin thun li tr gip ngi dn sng mt cuc sng khe mnh. Vic u tin l trao quyn cho ngi dn vi nhng kin thc, k nng c cuc sng khe mnh. Vic th hai l cn c s nh hng ca cc nh hoch nh chnh sch theo ui, to ra cc chnh sch cng cng v chng trnh h tr cho sc khe. S h tr, ng h mnh m ca x hi cho hnh ng sc khe cn c khi xng, y mnh v duy tr. Mc tiu sc khe cho mi ngi s tr thnh hin thc khi qun chng nhn dn bit c quyn li, trch nhim ca h v ng h cc chnh sch, chin lc NCSK ca Nh nc v c s hiu bit su sc v ng li cc cp chnh quyn. NCSK c th c m t nh nhng hnh ng v x hi, gio dc v s cam kt chnh tr lm tng hiu bit chung ca cng ng v sc khe, nui dng, duy tr li sng lnh mnh v hnh ng cng ng trn c s trao quyn lm ch cho ngi dn thc hin quyn li v trch nhim ca mnh mt cch r rng. NCSK trong thc t l lm sng t li ch ca vic ci thin sc khe, y l mt tin trnh hnh ng ca cng ng, ca ngi hoch nh chnh sch, cc nh chuyn mn v cng chng ng h cho cc chnh sch h tr sc khe. N c thc hin thng qua cc hot ng vn ng, trao quyn lm ch cho ngi dn, xy dng h thng h tr x hi cho php ngi dn c c s la chn lnh mnh v sng mt cuc sng khe mnh. Khi nim NCSK c chp nhn v nh gi cao ti cc nc cng nghip v cng ang c ng dng ti cc nc ang pht trin. N c m t bng nhiu cch khc nhau, nh gio dc sc khe, truyn thng sc khe, vn ng x hi. Nhng vic ny trong thc t l nhng phn khng th tch ri, chng h tr, b sung cho nhau. Ti Hi ngh v NCSK Geneva nm 1989 ngoi "Li ku gi hnh ng", hi ngh cn thm d tnh hnh p dng khi nim v chin lc NCSK cc nc ang pht trin, v xut nhng cch thc c th nhng khi nim v chin lc ny c chuyn thnh hnh ng trong bi cnh ca cc quc gia ang pht trin. Tng cng GDSK v ci thin chnh sch y t, nhng chin lc v hnh ng v sc khe cc nc ang pht trin tr thnh cu phn khng th thiu c t c sc khe cho mi ngi. C nhiu yu t cho thy nhu cu cp thit cn phi y nhanh, y mnh hnh ng cho NCSK, v huy ng cc lc lng x hi cho y t. Nhm ng u trong nhng yu t ny l: Nhiu nc ang pht trin ang trong giai on chuyn dch m hnh sc khe. H chu mt gnh nng gp i - nhng bnh truyn nhim cha kim 18

sot c, gn lin vi xu hng tng lin tc t l mc cc bnh khng ly truyn, thm na l i dch HIV/AIDS. Tng trng dn s nhanh, th ha nhanh chng v ng thi vi s pht trin kinh t, x hi l s pht trin ca nhng vn v li sng v mi trng. L do c bn ca nhng vn ny l bt bnh ng, ngho i, iu kin sng thiu thn v thiu gio dc, chnh l nhng iu kin tin quyt m bo mt cuc sng khe mnh. Cng bng x hi v quyn con ngi ph n, tr em, cng nhn v cc nhm dn tc thiu s ang dn dn thu ht s ch ca mi ngi v l ch chnh cho nhng hnh ng quc gia. Sc khe l thnh t quan trng ca nhng ch ny v ang l thch thc i vi tt c cc quc gia trong vic ci thin cht lng cuc sng ca ngi dn. Ngi dn khe mnh s hnh thnh x hi khe mnh, to ng lc pht trin kinh t v x hi, gip cho cc quc gia cng thnh. V th c ngun nhn lc khe mnh trong x hi l mc ch ca cc quc gia. Nhng sc khe vn cha c nhn thc mt cch ng n nh l mt s tch hp gia cc thnh phn cn thit ca s pht trin kinh t - x hi, d cho thc t iu ny c i Hi ng Lin hip quc v i Hi ng Y t Th gii tng nhn mnh. Nhng nh hoch nh chnh sch, lp k hoch, ra quyt nh phi c thuyt phc v nhu cu ca s tch hp, lng ghp cc vn lin quan n sc khe vo tt c nhng hot ng pht trin, mc d nhng vn mi trng, kinh t v sc khe i khi c nhng mu thun ca n. Vn ng i chng bo v mi trng l s huy ng v tp hp nhng sc mnh chnh tr v x hi. Chng c ngha cho nhng hnh ng tng cng, nng cao sc khe trong tng lai.
3.3.2. Chin lc nng cao sc khe

Nng cao kin thc v hiu bit v sc khe l mt bc khng th thiu c trong vic y mnh hnh ng h tr sc khe. To ra nhng iu kin x hi, kinh t, v mi trng thun li dn n vic ci thin sc khe l ht sc cn thit. Nhng iu ny v s tr thnh hin thc ch khi c hiu bit thu o v nhng vn sc khe ca cc nh hoch nh chnh sch, chnh tr gia, ngi lp k hoch kinh t v mi ngi dn; v khi nhng hiu bit ny c chuyn ha vo trong chnh sch, lut php v s phn b ngun lc cho sc khe. Khng c g cn thit hn bng s huy ng ton b nhng sc mnh ca x hi cho s khe mnh v hnh phc ca con ngi. Ba chin lc c bn ca hnh ng x hi c thit lp mt cch r rng trong bo co ca vn kin "Li ku gi hnh ng". Nhng chin lc ny l vn ng cho sc khe; h tr x hi v trao quyn lm ch cho ngi dn. Nhng chin lc ny cu thnh mt cng c c sc mnh y mnh, ci thin li sng lnh mnh v to ra nhng iu kin thun li dn n vic ci thin sc khe. Mi chin lc c nhng c im ring v ni dung trng im ca n. 19

Vn ng khuyn khch v to sc p i vi cc nh lnh o, ngi hoch nh chnh sch, ngi lm lut h c hnh ng ng h, h tr cho sc khe. H tr x hi, bao gm h tr cho h thng y t, nhng iu kin tng cng v duy tr bn vng s to c s cho php ngi dn c c nhng hot ng h tr cho sc khe v m bo c c tnh trng cng bng, trong chm sc sc khe. Trao quyn lm ch l cung cp cho cc c nhn, nhm ngi dn nhng kin thc, k nng hnh ng v sc khe mt cch ch ng. Can thip NCSK hiu qu c p dng cc nc ang pht trin thng phi gii quyt ba lnh vc hnh ng chnh l: GDSK, Ci thin cht lng dch v v Vn ng (S 1.1). GDSK c coi nh mt thnh phn quan trng nht ca NCSK, cc hot ng GDSK hng n c nhn, gia nh v cng ng nhm thc y chp nhn hnh vi lnh mnh, gip ngi dn c nng lc v t tin hnh ng. Ci thin dch v gm ci thin ni dung, loi hnh ca dch v; ci thin kh nng tip cn dch v ca ngi dn v tng cng kh nng chp nhn s dng dch v. Vn ng tc ng n cc nh hoch nh chnh sch, xy dng lut, qui nh lin quan n vic phn b ngun lc, nh hng hot ng dch v v tng cng tun th lut php.

Nng cao sc khe

Gio dc sc khe

Ci thin dch v sc khe

Vn ng cho sc khe

Tc ng n: Hiu bit/Kin thc; Quyt nh; Nim tin/ Thi ; Trao quyn; Thay i hnh vi/Hnh ng ca c nhn v cng ng; S tham gia ca cng ng

Ci thin cht lng v s lng dch v: Kh nng tip cn; t vn; cung cp thuc men; thi nhn vin; qun l ca bnh; tip th x hi

Thit lp chng trnh ngh s v vn ng cc chnh sch cng c li cho sc khe: Chnh sch y t; chnh sch lin quan n ci thin i sng; Gim thiu s phn bit i x, bt bnh ng; cc ro cn v gii trong CSSK

S 1.1. Cc thnh phn ca NCSK Nh vy chng ta c th nhn thy rng NCSK bao gm tt c nhng hot ng nhm phng nga bnh tt hoc lm cho tnh trng sc khe tt hn. Bng 1.1 a ra mt s v d v cc hot ng NCSK. Chng ta cn xc nh v nh gi nhng chin lc, cc chng trnh NCSK ang tin hnh mt cch khoa hc to c c nhng bi hc kinh nghim, tip tc thit k v trin khai nhng chin lc mi. S rt hu ch nu Vit Nam tip thu nhng kinh nghim qu bu cc quc gia pht trin v ang pht trin khc vi cc bi hc rt ra t nhng chng trnh sc khe t chng ta c th chn lc v ng dng mt cch thch hp v hiu qu. 20

Bng 1.1. Mt s v d v hot ng NCSK 1. Gio dc sc khe Nng cao hiu bit v cc vn sc khe Gip ngi dn t c nhng kin thc, k nng cn thit c c sc khe tt hn. 2. Bo v c nhn Tim chng Lut s dng dy an ton khi i xe t S dng m bo him Mc qun o bo h khi lm vic Chng trnh i bm kim tim cho ngi tim chch ma ty 3. Lm cho mi trng trong sch, an ton Qun l nc thi, cht thi Ci thin tnh trng nh Ci thin tnh trng ng x, gim thiu nguy c tai nn Lut an ton lao ng ti ni lm vic V sinh thc phm 4. Pht hin nhng vn sc khe giai on c th cha tr sm 5. To iu kin d dng la chn nhng yu t c li cho sc khe 6. Hn ch nhng hot ng, sn phm c hi cho sc khe Sng lc ung th c t cung Sng lc ung th v nh gi yu t nguy c bnh mch vnh Tng tnh sn c ca nhng sn phm c li cho sc khe Tr gi nhng sn phm c li cho sc khe Kim sot qung co nhng th c hi cho sc khe nh thu cao nhng sn phm c hi cho sc khe Cm lu hnh nhng sn phm gy hi cho sc khe

Bc vo th k XXI, cng vi cng cuc cng nghip ha v hin i ha t nc, ng v Chnh ph Vit Nam ch o cht ch cng tc chm sc v bo v sc khe ca nhn dn. Ngh quyt i hi ng ln th IX v Chin lc chm sc bo v sc khe nhn dn giai on 2001-2010 vch ra phng hng pht trin tng th nng cao sc khe nhn dn trong tnh hnh mi. c bit ngy 22/01/2002, Ban chp hnh Trung ng ng ra Ch th s 06-CT/TW v cng c v hon thin mng li y t c s nhm tng cng hn na cng tc chm sc sc khe ban u. Vit Nam, ngy 19/03/2001, Th tng Chnh ph ph duyt Chin lc Chm sc v bo v sc khe cho nhn dn giai on 2001 - 2010. Mc tiu chung ca Chin lc ny l Phn u mi ngi dn c hng cc dch v CSSKB, c iu kin tip cn v s dng cc dch v y t c cht lng. Mi ngi u c sng trong cng ng an ton, pht trin tt v th cht v tinh thn. Gim t l mc bnh, nng cao th lc, tng tui th v pht trin ging ni. Trong cc gii php chnh thc hin chin lc c gii php y mnh cng tc y t d phng, nng cao sc khe. Trong nm 2001, Chnh ph cng ph duyt nhiu Chin lc, Chng trnh hnh ng quc gia ngn hn hn nh: Chng trnh mc tiu quc gia phng chng 21

mt s bnh x hi v HIV/AIDS giai on 2001-2005, Chnh sch quc gia phng chng tc hi ca thuc l giai on 2001-2010, Chnh sch quc gia phng chng tai nn, thng tch giai on 2002-2010, Chin lc quc gia v Sc khe sinh sn, Chin lc quc gia v dinh dng giai on 2001-2010... Nhiu ch s sc khe c nu ra chnh l nhng mc quan trng ngnh Y t, cc ngnh khc, ngi dn nhn thc mt cch ng n v cng tham gia thc hin. Ngy 23/02/2005, Ban Khoa gio Trung ng ra Cng vn s 49 v vic hng dn thc hin Ngh quyt 46-CT/TW ca B Chnh tr v cng tc bo v chm sc v nng cao sc kho nhn dn trong tnh hnh mi. Ngh quyt ny xc nh cc quan im ch o, mc tiu cng nh cc nhim v v gii php nhm hon thin v pht trin h thng y t nc ta, p ng yu cu ngy cng cao ca nhn dn v bo v, chm sc v nng cao sc kho, phc v c lc s nghip cng nghip ho, hin i ho, xy dng v bo v T quc. y l mt vn kin quan trng ca ng, nh hng cho lnh vc bo v, chm sc v nng cao sc kho nhn dn trong 10-15 nm ti, khi m th ch kinh t th trng nh hng x hi ch ngha ang c hnh thnh. Vic trin khai thc hin Ngh quyt phi c tin hnh trong nhiu nm lin tc theo mt chng trnh hnh ng thng nht v ng b ph hp vi tng cp, tng ngnh, on th. Nhng hng dn c th t B Y t v cc c quan chc nng s l cn c php l thit k v trin khai nhng chng trnh NCSK trn a bn c nc.
4. CC NGUYN TC CHNH CA NNG CAO SC KHO

T chc Y t Th gii nu ra nm nguyn tc chnh ca NCSK nh sau:

1. NCSK gn lin vi qun th dn c trong khung cnh chung ca cuc sng

hng ngy ca h, hn l tp trung vo nhng nguy c, ri ro ca nhng bnh tt c th.

2. NCSK hng n hnh ng gii quyt cc nguyn nhn hoc nhng yu t

quyt nh sc khe nhm m bo mt mi trng tng th dn n vic ci thin sc khe.

3. NCSK phi hp nhiu phng php hoc cch tip cn khc nhau, nhng b

tr cho nhau, bao gm: truyn thng, gio dc, lut php, bin php ti chnh, thay i t chc, pht trin cng ng v nhng hot ng c th ca tng a phng chng li nhng mi nguy hi cho sc khe.
4. c bit, NCSK nhm vo s tham gia hiu qu ca cng ng da trn nhng

phong tro t ch v ng vin, c v ngi dn tm ra nhng cch thc ph hp vi chnh h chm sc, bo v sc khe cng ng ca chnh h.
5. NCSK v c bn l cc hot ng trong lnh vc y t, x hi, khng phi l

mt dch v y t lm sng, nhng cn b chuyn mn v sc khe - c bit trong CSSKB - c mt vai tr quan trng trong vic duy tr v y mnh nhng hot ng NCSK (WHO 1977). Pht trin nhng chin lc sc khe trn phm vi rng v th cn c da trn s cng bng, tham gia ca cng ng, v cng tc lin ngnh. Nhng iu kin tin 22

quyt cho sc khe, bao gm c nhng cam kt chnh tr v h tr x hi cn phi xem xt k lng. NCSK l mt thut ng c ngha rng, bao hm nhng chin lc can thip khc nhau. Qu trnh ny c xem nh hng lot hot ng c h thng, c ch ch r rng phng nga bnh tt v au yu, gio dc ngi dn li sng lnh mnh hn, hoc ch r nhng yu t x hi v mi trng nh hng n sc khe ngi dn. NCSK cn c xem nh mt h thng ca nhng nguyn tc nh hng cng tc y t nhm tng cng s cng tc, tham gia v xc nh s bt bnh ng trong chm sc sc khe. V th ngi lm cng tc NCSK cn nhn thc v hiu r v khi nim sc khe, GDSK, NCSK nh hng hot ng v tc ng thay i hnh vi c nhn, cc yu t lin quan tng cng sc khe ngi dn mt cch hiu qu.
cu hi THO LUN

Nu v gii thch mt s hot ng Gio dc sc khe v Nng cao sc khe in hnh ti a phng. Nu cc v d v cc hot ng lin quan n 5 lnh vc hnh ng cp trong tuyn ngn Ottawa.
TI LIU THAM KHO
1. B Y t (1994). Gio trnh Nng cao k nng ging dy v Truyn thng-

Gio dc sc khe.
2. B Y t (2000). Chin lc chm sc v bo v sc khe nhn dn giai on

2001-2010.
3. Egger, Spark, Lawson, Donovan, (1999). Health Promotion Strategies and

Methods, p: 1-15.
4. Glanz, K., Lewis, F.M., & Rimer, B.K. (1997). Health Behavior and Health

Education: Theory, Research, and Practice. 2nd edition. San Francisco, CA: Jossey-Bass Publishers.
5. Jenie Naidoo, Jane Wills (2000). Health Promotion-Foundations for

Practice, p: 27-48.
6. John Hubley (2004). Communicating Health, An action guide to Health

Education and Health Promotion. 2nd edition, p:12-18.

7. John Kemm, Ann Close (1995). Health Promotion-Theory and Practice, p:

3-37.
8. John Walley, John Wright, John Huble (2001). Public Health, An action

guide to Improving Health in Developing Countries, Oxford University Press, p: 141-152.

9. WHO (1994). Health Promotion and Community action for Health in

developing countries, p: 1-6. 23

Bi 2

HNH VI SC KHO V QU TRNH THAY I HNH VI

MC TIU
1. Gii thch c nhng yu t quyt nh sc khe. 2.

Trnh by c khi nim hnh vi, hnh vi sc kho.

3. Phn tch c cc yu t c bn nh hng n hnh vi sc khe. 4. Trnh by c cc m hnh l thuyt gii thch v d on qu trnh thay i

hnh vi c nhn.
5. Trnh by c cc iu kin tin quyt ca qu trnh thay i hnh vi v

cc chin lc can thip ph hp theo tng giai on thay i hnh vi.

1. NHNG YU T QUYT NH SC KHO

Vi nhng hiu bit c bn, chng ta c th nhn thy c mt s yu t gp phn lm cho con ngi khe mnh v duy tr c sc khe ca h, cng nh nhng nguyn nhn lm cho con ngi b au m (xem thm s 2.1). C th lit k mt s v d v cc yu t gy tc ng xu n sc khe nh: Yu t di truyn trong mt s bnh nh hng cu lim, i tho ng, thiu nng tr tu c th gy hu qu xu cho th h con ci. Cc tc nhn nh b nh vi khun, virus, nm, giun sn... c th xm nhp vo c th qua tip xc, qua thc n, do ht phi hoc do cn trng hay cc con vt khc t, cn, co t gy bnh. Cc ha cht nh du ha, thuc tr su, kh t, phn bn, ch v acid c th gy ng c hoc c hi cho c th khi tip xc qu mc. Thm ch mt s thuc cha bnh nu dng khng ng c th dn n nhng tc dng ph ngoi mun. Yu t mi trng nh: lt li, bo, ng t, cc thin tai khc c th gy thng tch hoc t vong nhiu ngi. Nhiu yu t khc c th l nguy c tim n gy ra tai nn nh: chy n, nh ca ti tn, ng x xung cp... Nhng iu kin kh khn v nh , ni lm vic, trong gia nh v cng ng d dn n cc vn v sc khe tm thn. Tuy nhin, nhng yu t trn khng phi bt c lc no cng c th gy tn thng, gy bnh tt, m au cho con ngi. Nu ngi dn hiu r v bit cch ng ph vi nhng nguy c tim tng ny th h c th phng trnh c nhiu bnh tt v nhng iu bt li cho sc khe. Cc nguy c tim n, cc 24

yu t quyt nh sc khe c chia thnh bn nhm chnh, l: yu t sinh hc hay yu t di truyn; yu t v hnh vi hay phong cch sng; yu t cht lng ca dch v chm sc sc khe v yu t mi trng, bao gm c mi trng t nhin v x hi nh: khng kh, ngun nc, t, iu kin sng v lm vic...

Mi trng

Hnh vi/Phong cch sng

Sc khe

Dch v y t

Yu t sinh hc

S 2.1. Cc yu t nh hng n sc khe (Lalonde Report, 1974) Trong cch gii thch v cc yu t nh hng n sc khe, tc gi Dahlgren v Whitehead (1991) cng nu ra bn nhm yu t chnh v th hin chi tit hn cc yu t tc ng n sc khe (S 2.2) l: Hnh vi c nhn v li sng ca con ngi. Nhng h tr v nh hng ln nhau trong cng ng. iu kin sng v lm vic, kh nng tip cn dch v y t. Nhng iu kin kinh t, x hi v mi trng.
1.1. Cc yu t v di truyn

Cc yu t sinh hc quyt nh cu trc c th v cc hot ng chc nng ca c th. Gn y, khoa hc chng minh khi c s bin i, bt thng trong cu trc ca nhng on gen no c th gy ra nhng bnh tt tng ng. Hin nay khoa hc y hc c th s dng bn gen lm cng c chn on mt s bnh nh: thiu mu do hng cu hnh lim, bnh x nang ty, bnh i tho ng... Phn ln cc yu t gen thng khng th thay i c v n nay y hc mi ch c th can thip c mc hn ch.

25

iu kin kinh t, vn ha, x hi v mi trng chung

iu kin sng v lm vic: nh , lng thc, thc phm, nc sch, hc vn, vic lm, tip cn dch v y t, mi trng lm vic

Mng li x hi v cng ng

Hnh vi, li sng

Tui, gii, yu t di truyn

S 2.2: Cc yu t chnh quyt nh sc khe (Dahlgren v Whitehead, 1991)

1.2. Yu t mi trng

Yu t mi trng v s tip tc ng mt vai tr ht sc quan trng quyt nh tnh trng sc khe ca bt c mt cng ng no. Thut ng mi trng y c hiu theo ngha rng, bao gm: mi trng x hi, t chc x hi, cc ngun lc... Mi trng t nhin nh: nhit , nh sng, khng kh, t, nc; cc thin tai, thm ha. Mi trng sng, lm vic c th nh: tnh trng nh , ng x, nh my cng nghip, c quan, bnh vin, hm m...
1.3. Nhng yu t lin quan n h thng chm sc sc khe

H thng chm sc sc khe c nh hng ng k n trng thi sc khe ca ngi dn. Cht lng iu tr v chm sc nh th no; tnh trng thuc men c y hay khng; kh nng tip cn vi dch v ca ngi dn (chi ph, khong cch tip cn cc dch v y t, thi gian ch i ...); thi ca cn b y t i vi ngi bnh; trnh chuyn mn ca cn b y t c p ng c yu cu khng, tnh cht ca h thng chm sc sc khe (CSSKB hay chuyn ngnh, y t nh nc hay y t t nhn). Tnh trng tiu cc ca nhng yu t thuc h thng chm sc sc khe ny s c nh hng xu n tnh trng sc khe ca ngi dn, ca cng ng ni chung. 26

1.4. Yu t hnh vi v li sng ca con ngi

Phn ny c cp chi tit trong mc 2 di y.

2. HNH VI SC KHO V NHNG YU T NH HNG 2.1. Hnh vi sc khe

Hnh vi l cch ng x ca con ngi i vi mt s vt, s kin, hin tng trong mt hon cnh, tnh hung c th, c biu hin bng li ni, c ch, hnh ng nht nh. Hnh vi hm cha cc yu t nhn thc, kin thc, thi , nim tin, gi tr x hi c th ca mi con ngi. Cc yu t ny thng an xen, lin kt cht ch vi nhau, kh c th phn tch r rng. Hnh vi sc khe l hnh vi ca con ngi c lin quan n vic to ra, bo v v nng cao sc khe, hoc lin quan n mt vn sc khe nht nh, nh: hnh vi tp th dc bui sng, hnh vi v dinh dng, v v sinh mi trng... Hnh vi sc khe ca c nhn l trng tm ca qu trnh GDSK v NCSK. Gochman (1982) nh ngha hnh vi sc khe l nhng thuc tnh c nhn nh nim tin, s mong i, ng lc thc y, gi tr, nhn thc, v kinh nghim; nhng c im v tnh cch bao gm tnh cm, cm xc; cc loi hnh hnh vi, hnh ng, v thi quen c lin quan n s duy tr, phc hi, v ci thin sc khe. Hnh vi sc khe c khi r rng, cng khai, c th quan st c nh ht thuc l, cng c khi l nhng trng thi cm xc khng d dng quan st c nh thi i vi vic dng m bo him khi i xe my... Theo xu th thay i m hnh bnh tt, t l cc bnh tt lin quan n hnh vi c nhn c xu hng tng nh: chn thng do tai nn giao thng, bnh tim mch, ung th phi, lm dng thuc, bo ph, HIV/AIDS, cc bnh ly truyn qua ng tnh dc..., cho thy hnh vi sc khe ca c nhn ng vai tr quan trng cho qu trnh n lc nng cao sc khe ca ngi dn. Nhng hnh vi sc khe nh ht thuc l, s dng m bo him, ung bia ru, dng bao cao su trong quan h tnh dc, ch n ung, tp th dc... cho thy r tc ng quan trng ca chng vi trng thi sc khe ca c nhn v ca x hi. i dch HIV/AIDS l mt v d. y l mt vn sc khe c lin quan cht ch vi hnh vi sc khe c nhn. S iu , an ton trong quan h tnh dc, s dng bao cao su trong quan h tnh dc, v trnh dng bm kim tim khng tit trng l mt vi v d v hnh vi c li cho sc khe c xc nhn l c hiu qu trong cng cuc phng chng s lan truyn HIV/AIDS. Con ngi khe mnh hoc au m thng l hu qu ca chnh hnh vi ca h. C nhng hnh vi lnh mnh, c li cho sc khe nh: ra tay trc khi n, nm mn khi ng, phun thuc dit mui s chng li cc loi mui truyn bnh; khng ht thuc l s gim c nguy c ung th phi; nui con bng sa m c th ngn nga tr b tiu chy v suy dinh dng... Ngc li cng c nhng hnh vi ca con ngi c th gy nh hng xu n sc khe ca chnh h hoc cho nhng ngi xung quanh nh: i xe my trn ng cao tc m khng i m bo him; ht thuc l, n nhiu cht bo, ung nhiu bia, ru, ung nc l, quan h tnh dc khng an ton, tim chch ma ty... Cng c nhng hnh vi v hi i vi sc khe nh eo vng bc c tay, c 27

chn tr em... Vic xc nh c hnh vi no gy ra bnh tt, hnh vi no phng nga c bnh tt l iu rt quan trng trong NCSK.
V d: Tiu chy tr nh: Mt s hnh vi c th l nguyn nhn gy ra tiu chy nh: Ung nc sng, sui, ao, h m khng un si. Cc dng c, dng cho tr n khng c ra sch. Qun l phn, rc khng tt dn n vic nhim bn cc vt m tr tip xc v c th a vo ming. Thc n cho tr khng c bo qun tt. Cho tr n thc phm lu, i thiu.

Mt s vic lm c th trnh c tiu chy cho tr em nh: Cho tr b m hon ton trong 6 thng u. Bnh sa, cc dng cho tr n phi m bo v sinh. Ra tay sch trc khi cho tr n. Bo qun thc n ng cch. Ung nc un si ngui.

Hnh vi hoc li sng khng lnh mnh c xem l nguyn nhn dn n bnh tt, t vong v cc vn sc khe khc. Mt s nghin cu ch ra s lin quan gia hnh vi c nhn vi bnh tt.
Ht thuc l l nguyn nhn ch yu ca cc bnh ung th phi, bnh tim mch. Thi quen v sinh rng ming km lin quan n su rng. Lm dng ru l nguy c ca cc bnh tim mch; ung ru trc khi li xe l nguyn nhn ch yu ca cc tai nn giao thng. Li sng khng v sinh lin quan ti cc bnh nhim trng, thi quen n ung lin quan ti cc bnh dinh dng, chuyn ha.....

Trong nhiu thp k qua, m hnh bnh tt trn ton th gii ni chung v Vit Nam ni ring c nhiu thay i. Cc bnh nhim trng cp tnh nh bnh lao, si khng cn ph bin nh trc, bnh bi lit c thanh ton nh hiu qu ca chng trnh tim chng. Trong khi , nhng loi hnh bnh tt c th ngn nga c li c xu hng gia tng nh ung th phi, bnh mch vnh, x va ng mch, chng nghin ru, ma tu v cc vn chn thng giao thng. Vai tr ca yu t hnh vi i vi nhng vn sc khe va nu c chng minh (xem Bng 2.1). V d, c th trnh c 25% tng s t vong do ung th v nhiu trng hp t vong do au tim ch bng cch iu chnh mt hnh vi nh khng ht thuc l. Ch cn 10% n ng trong tui t 35 n 55 gim cn lm gim 28

khong 20% bnh v tim, ung th d dy, i tho ng, t qu. Ni chung, khong 50% s t vong do 10 nguyn nhn gy t vong hng u l do nhng yu t v li sng m nhng yu t ny u c th iu chnh c. Thnh cng trong vic iu chnh cc hnh vi sc khe s mang li mt s tc ng c li nh gp phn lm gim s t vong do nhng cn bnh lin quan n li sng; c th tr hon thi gian dn n t vong, v th ko di tui th ca c nhn v tui th trung bnh chung ca qun th; c th tit kim c khon chi ph ln cho iu tr v chm sc bnh nhn. S liu bng 2.2 cho thy chi ph cha tr mt s bnh rt ln m ng ra c th tit kim c. Bng 2.1. Nhng yu t nguy c dn n nhng nguyn nhn gy t vong hng u
Bnh Bnh tim Ung th t qu Cc chn thng do tai nn Bnh phi mn tnh Nhng yu t nguy c Thuc l, bo ph, cao huyt p, cht bo gy x cng ng mch, li sng t vn ng. Thuc l, n king khng ng cch, ru, chu tc ng ca mi trng Thuc l, cao huyt p, cht bo gy x cng ng mch, li sng t vn ng Khng dng m bo him khi li xe, ung ru, nhng ri ro, tai nn nh. Thuc l, chu tc ng ca mi trng

(Theo M. McGinnis, 1994)

Bng 2.2. Chi ph iu tr mt s vn sc khe c th ngn nga c

Vn sc khe Can thip c th trnh c Chi ph / bnh nhn (USD) Bnh tim Ung th Cc chn thng Tr s sinh nh cn Phu thut tim iu tr ung th phi iu tr v phc hi.... iu tr v phc hi gy xng chu iu tr hi chng thiu nng h hp 30.000 29.000 570.000 (c i) 40.000 26.500

(Theo M. McGinnis, 1994)

Hnh vi ca con ngi, c bit l hnh vi sc khe, thng phc tp v khng phi lc no cng c hiu mt cch r rng. Qua nhiu nm, c nhiu l thuyt c gng a ra s gii thch v hnh vi. Tuy nhin, cho n nay cha c l thuyt no gii thch mt cch ton din v nhng kha cnh ca hnh vi con ngi gp phn gii quyt nhng vn sc khe.

29

2.2. Nhng yu t nh hng n hnh vi sc khe

C rt nhiu l do lm cho con ngi c nhng cch ng x, nhng hnh vi nh h vn thng th hin hng ngy. Nu chng ta mun GDSK to ra v thc y nhng hnh vi lnh mnh th chng ta phi hiu r nhng yu t nh hng, nhng nguyn nhn dn n hnh vi sc khe. Trong mt m hnh lp k hoch tng th, cc tc gi Green v Kreuter (1980, 1991, 1999) phn ra ba nhm yu t chnh gp phn hnh thnh v tc ng trc tip hoc gin tip n cch ng x, hnh vi con ngi, l:
2.2.1. Nhng yu t tin (Predisposing factors)

Nhng yu t tin l yu t bn trong ca c nhn c hnh thnh trn c s kin thc, thi , nim tin, gi tr, chun mc x hi ca mi c nhn. Nhm yu t ny quyt nh cch ng x ca chng ta, cho ta nhng suy ngh, nhng cm xc i vi th gii xung quanh. Kin thc thng bt ngun t s hc tp, tri nghim. Kin thc l s hiu bit, kinh nghim c tng hp, khi qut ha. Chng ta tip thu kin thc t cha m, gio vin, bn b, sch v, bo ch, phim nh. Ngi ta thng c th kim tra kin thc ca mnh ng hay khng ng, v d th tay vo bp la s c cm gic v nng v au. S tri nghim ny s ngn nga cho ngi khng lp li hnh ng tng t. Ngi ta c th chng kin mt ngi khng i m bo him i xe my b tai nn ri t vong do chn thng u. T kinh nghim ny h hc c rng nu i xe my m khng i m bo him th rt nguy him v cn phi thn trng hn khi i xe my. Thi th hin mt phn ng, quan im ca c nhn i vi mt ngi, s kin, quan im no . N phn nh nhng g ngi ta thch hoc khng thch, ng h hoc khng ng h. Thi bt ngun t nhng tri nghim ca bn thn hoc t nhng ngi thn. Thi biu hin s thch th, tin tng, ng h iu ny hoc phng, cnh gic vi iu khc ca chng ta. Tuy nhin, thc t cho thy ngi ta khng lun ng x theo thi ca h. Nim tin l s tin tng chc chn rng mt s kin, quan im l ng, l c tht mc d c th khng ng, khng c tht. Nim tin ny thng do cha m, ng b, v nhng ngi thn m ta thng yu, knh trng truyn t, khuyn bo hoc c c t kinh nghim bn thn. Ngi ta thng c xu hng tip nhn nim tin m khng kim chng li xem nim tin c ng khng. V d: C nhng nhm ngi cho rng ph n c thai khng nn n tht mt s ng vt v nu n a tr sau ny sinh ra c th c hnh vi hoc mt s c im ging nh con vt m ngi m tng n. C nhiu b m tin rng khi c thai nu n qu nhiu th s kh v a con qu to. Nhng nim tin thiu c s khoa hc nh th lm cho b m c nhng hnh vi c hi cho sc khe ca chnh h v con ci h. Nim tin l mt phn ca cuc sng con ngi. Mi cng ng, mi nhm ngi c th c nhng nim 30

tin khc nhau, tri ngc nhau. Nim tin ca con ngi thng kh thay i. Mt khi bn hiu rng nim tin c nh hng n sc khe nh th no th bn mi c th c k hoch ph hp cho s thay i nhng nim tin c hi ny. Nu nim tin khng nh hng xu n sc khe th khng nht thit phi thay i. Nu can thip qu nhiu n nim tin ca ngi dn c th lm gim mc cng tc ca h vi cn b y t. Gi tr x hi: Trong khoa hc x hi, gi tr c coi l nhng mi quan tm, s thch, bn phn, trch nhim, c mun, nhu cu v nhiu hnh thi khc ca nh hng la chn. Mi gi tr dng nh cha ng mt s yu t nhn thc. Chng c tnh cht hng dn v nh hng. Khi c nhn thc mt cch y , cc gi tr s tr thnh nhng tiu chun cho s a thch, la chn v phn xt. Vy gi tr l iu m con ngi cho l ng n, l ng c, m chng ta a thch, chng ta cho l quan trng nh hng cho cc hnh ng ca chng ta. Gi tr x hi chnh l iu c cng ng, x hi coi l tt p v c ngha, n lm c s phn xt cc hot ng trong cuc sng hng ngy ca con ngi. Phn ln cc gi tr c bn ca x hi c con ngi tip nhn ngay khi cn nh thng qua gia nh, nh trng, bn b, thng tin i chng v cc ngun khc. Nhng gi tr ny tr thnh mt phn ca nhn cch con ngi. V gi tr ch ra ci g l ph hp, ci g khng ph hp vi c nhn, vi cng ng, vi x hi, nn chng ng thi chp nhn nhng kiu hnh vi ph hp v ph nhn nhng hnh vi khc khng ph hp vi gi tr x hi. Chun mc: L nhng mong i, nhng yu cu, nhng qui tc x hi c ghi nhn bng li, bng ch vit, bng k hiu nh hng hnh vi cc thnh vin trong x hi. Chng xc nh r cho con ngi ci g nn lm, ci g khng nn lm v phi x s th no cho ng trong cc tnh hung. Nu gi tr l nhng quan nim kh tru tng v iu quan trng, ci ng gi, th chun mc l cc tiu chun, qui c, hng dn i vi hnh vi c th, thc t ca con ngi. Gi tr t b chi phi bi hon cnh hn, c tnh khi qut hn, cn chun mc thng lin kt cc gi tr vi cc s kin thc t. Chun mc quan trng nht i vi mi x hi l php lut. y l nhng chun mc c tnh php ch. N qui nh nhng hnh vi c php v khng c php thc hin, trong c cc hnh vi sc khe. V d: khi cng ng khe mnh l gi tr x hi, th khng ht thuc l ni cng cng, v sinh mi trng quanh h gia nh... l cc chun mc. Yu t vn ha c hnh thnh v pht trin trong mi quan h gia con ngi v x hi, n cng chnh l tng ha ca cc yu t va nu trn c nh hng nhiu n hnh vi ca ngi dn. Mi cng ng, mi quc gia, mi dn tc u c nhng nt vn ha ring ca mnh. N c biu hin qua cch sng ca h. Hnh vi l mt trong nhng kha cnh ca vn ha v ngc li, vn ha c nh hng su sc n nim tin, thi , chun mc. Ty theo vn ha m cch n ung, sinh hot, chm sc sc khe... c nhng nt ring. Vic hiu bit ton din v vn ha ca mt cng ng c th gip cho ngi cn b y t xc nh ng cc yu t nh hng ti hnh vi sc khe, t 31

lm tt cng tc truyn thng, gio dc sc khe ca mnh, gp phn lm cho qu trnh NCSK t c mc ch.
2.2.2. Nhng yu t cng c (Reinforcing factors)

l nhng yu t nh hng t pha ngi thn trong gia nh (cha m, ng b), thy, c gio, bn b, ng nghip, nhng ngi ng u a phng, nhng v lnh o, nhng ngi c chc sc trong cc tn gio... H chnh l nhng ngi c uy tn, quan trng i vi cng ng, gp phn to nn nim tin, thi , chun mc ca cng ng . Con ngi thng c xu hng nghe v lm theo nhng g m nhng ngi c uy tn, quan trng i vi h lm. V d: Hc sinh thng ra tay trc khi n nu cc em thy thy c gio cng lm nh vy; mt tr nam c th d dng ht thuc nu trong s bn thn ca em c ngi ht thuc.
2.2.3. Nhng yu t to iu kin thun li (Enabling factors)

Ngoi cc yu t c nhn, cc yu t cng c nh nu, cn c cc yu t nh hng n hnh vi ca con ngi m chng ta cn phi xem xt n nh: ni sinh sng, iu kin v nh , hng xm lng ging xung quanh, vic lm, thu nhp ca h, cng nh cc chnh sch chung v mi trng lut php. l nhm cc yu t lin quan n ngun lc ni chung c nh hng rt ln n hnh vi con ngi, l nhm cc yu t to iu kin thun li cho vic thc hin v duy tr hnh vi ca c nhn. Mt s v d minh ha: Mt b m mun c khm thai trm x x nhng v phi i b qu xa nn khng n khm. Mt s ngi c th lm nhng vic nguy him, hoc c nguy c cao nhng h vn phi lm v k sinh nhai nh nhng ngi ngp ln vt ct di y sng m khng c dng c bo h. Ngi dn ca mt ngi lng rt cn c ngun nc sch s dng, nhng chi ph cho vic khoan ging qu cao nn h khng th c ging khoan, v vy h vn phi tip tc dng nc sui khng t tiu chun v sinh. Yu t v mi trng php lut nh cc qui nh, lut php c tc ng rt mnh n hnh vi c nhn. Mt ngi c th ht thuc l ni cng cng v khng c qui nh cm ht thuc rng buc v ngi c th d dng mua thuc l vi gi r nhiu ni. Hin tng ht thuc trong bnh vin v trng hc s khng xy ra nu c qui nh cm ht thuc v vic x pht nhng ngi ht thuc trong cc khu vc ny c p dng nghim ngt. Ngc li, s c nhiu ngi i xe my vt n nu khng c s gim st v x pht nghim ca cnh st. S hiu bit ng n v cc yu t nh hng, l do dn n mt hnh vi no s gip chng ta la chn nhng phng php gio dc, nhng gii php can thip thch hp cho mt vn sc khe, cng nh xy dng c nhng chnh sch, to ra c mi trng h tr hiu qu cho s duy tr bn vng nhng hnh vi c li cho sc khe. Trong cuc sng thc t c nhiu loi hnh vi lm tng cng, bo v sc khe nh: tp th dc bui sng, n ung iu , thi quen v sinh mi trng...; chng ta cn khuyn khch, thc y mi ngi duy tr nhng hnh vi ny. Bn cnh , cng 32

c nhiu hnh vi c hi cho sc khe nh: ht thuc l, ung nhiu bia ru, nghin ma ty, khng tp th dc..., chng ta cn c nhng gii php can thip ci thin.
2.3. Cc cp nh hng n hnh vi sc khe

Phn trn cp n ba nhm yu t chnh nh hng n hnh vi l: yu t c nhn (nhm yu t tin ); nhm yu t cng c (yu t gia c nhn vi c nhn, yu t cng ng); nhm yu t to iu kin thun li/cho php (yu t lut php, chnh sch chung). Hnh vi ca con ngi hnh thnh trong mi quan h gia con ngi v x hi. V vy, cc chng trnh nng cao sc khe s tr nn hiu qu hn khi c s thay i tch cc mi trng x hi. Ngi ta a ra mt m hnh mi trng x hi tm hiu v gii thch v hnh vi sc khe. M hnh ny cp n nm cp nh hng c th quyt nh cc hnh vi sc khe, mi cp l mt i tng cho cc can thip ca chng trnh nng cao sc khe. Chng bao gm: cc yu t c nhn, mi quan h c nhn, cc yu t t chc, cc yu t v cng ng, v yu t lut php, chnh sch x hi tt c cc yu t ny u nh hng trc tip hoc gin tip n hnh vi sc khe ca c nhn trong mi tng quan n cc yu t ca cp khc (S 2.3).

Hnh vi sc kho

Cc yu t c nhn

nh hng t
gia nh, bn b, ng nghip

Mi trng hc tp, lm vic

Nhng nh hng t cng ng

Mi trng lut php

S 2.3. Cc cp nh hng n hnh vi sc kho

2.3.1. Cp nh hng th nht - Cc yu t c nhn

Cc yu t c nhn bao gm kin thc, thi v k nng ca tng c nhn. Cc yu t c nhn ny c cc l thuyt v tm l hc cp v nghin cu. Trn thc t mt s ngi tr nn quan tm v hng ti thay i hnh vi khi c gii thiu cc thng tin v nguy c sc khe. Ngc li mt s khc c th t chi nguy c ca h v khng hng ti thay i hnh vi. iu ny l do nhn thc nguy c mi ngi l khc nhau. Nhn thc v kh nng mc bnh, tnh trm trng ca vn v hu qu ca hnh vi cng khc nhau mi ngi. Nghin cu ca Weinberger, Greener, Mamlin v Jerin (1981) so snh s hiu bit v kh nng mc bnh v nh hng trm trng ca thuc l n sc khe ca nhng ngi ht thuc v nhng ngi khng ht thuc. Nhng ngi ht thuc c nim tin v hu qu ca vic ht thuc i vi sc khe khc vi nhng ngi ang ht thuc. Nhng ngi ht thuc nng nh gi hu qu ca ht thuc l t trm

33

trng. Trong khi rt nhiu ngi ang ht thuc cng nhn tc hi tim tng do ht thuc, nhng c c nhn li cho tc hi ca thuc l i vi mnh c th thp. Do vy cc cn b lm vic trong lnh vc NCSK cn hiu yu t no ng gp cho quyt nh thay i hnh vi ca c nhn, v yu t no gip mt s ngi c th iu chnh thay i hnh vi d dng hn nhng ngi khc. Khi phn tch yu t c nhn chng ta cn xem xt cc im sau: Quan im ca c nhn v nguyn nhn v vic phng nga bnh tt nh th no? C nhn c th iu khin cuc sng ca h n u v thay i hnh vi n mc no? C nhn c tin s thay i l cn thit khng? C nhn c nhn bit c vic thay i hnh vi khng lnh mnh l c li v lu di khng? Nhng kh khn v cc vn lin quan ti thay i hnh vi.
2.3.2. Cp nh hng th hai - Mi quan h c nhn

Cc mi quan h ca c nhn vi gia nh, bn b v ng nghip. Chng c nh hng rt ln n cc hnh vi sc khe. Gia nh l ni bt ngun ca rt nhiu hnh vi sc khe, c bit l cc thi quen hc c khi cn l mt a tr (v d: nh rng, tp th dc, cch n ung). Cc nghin cu hnh vi ht thuc ch ra nhng tr em trong gia nh c cha m ht thuc c nhiu kh nng s ht thuc hn cc tr em c cha m khng ht thuc. Vi la tui v thnh nin, nh hng ca bn b, ng ng thng tr nn quan trng hn (v d: ht thuc l, ung ru, s dng ma tu v tham gia vo cc hnh vi nguy him cho sc khe khc). S gip ca gia nh, bn b, ng nghip s l cc nhn t tch cc cho cc c nhn thay i hnh vi.
2.3.3. Cp nh hng th ba - Mi trng hc tp, lm vic

Mi trng hc tp, lm vic c vai tr rt quan trng bi v mi ngi dnh ra mt phn ba hoc mt na thi gian trong ngy ni lm vic hoc hc tp. V vy mi trng ny nh hng rt nhiu n sc khe v cc hnh vi bo v sc khe hoc hnh vi c hi cho sc khe. ni lm vic, cng nhn c th b tip xc vi cc ha cht c hi hoc lm vic trong mi trng c nguy c tai nn, chn thng, hoc c nhiu kh nng gy tnh trng cng thng (stress). Ngc li, ni lm vic c th to ra mt mi trng h tr cho vic thay i cc hnh vi c li cho sc khe. Nh n ca c quan hay trng hc c th cung cp cc ba n c cc cht dinh dng cn thit cho sc khe, ng thi cung cp thng tin, nhng ch dn v dinh dng cho cn b, hc sinh, sinh vin. C quan, trng hc c th xy dng cc phng tp th thao cho ngi lao ng hoc sinh vin. Ni lm vic v trng hc l mi trng thun li cm ht thuc l. V vy, trng hc v c quan lm vic l nhng ni l tng thc hin cc chng trnh nng cao sc khe v nhng can thip y t cng cng khc. V d: Cc quy nh v hn ch tc , i m bo him s hng c nhn c hnh vi li xe an ton. Cc quy nh "khng ht thuc l" ni lm vic, s tc ng 34

mnh ti thay i hnh vi ht thuc ca nhng ngi lm vic ti v nhng ngi khc n lm vic.
2.3.4. Cp nh hng th t - Cc yu t cng ng

Yu t cng ng bao gm cc mi quan h x hi, c cu x hi, phong tc, tp qun, vn ha v truyn thng tn ti trong cc nhm, t chc v c nhn trong cng ng c th nh hng mnh n hnh vi sc khe. Cc t chc x hi c th cng nhau phi hp thc hin cc chng trnh tng cng sc khe trong cng ng. V d: s phi hp cht ch gia hi ph n x v cng tc vin dn s x trong chng trnh dn s - k hoch ha gia nh s gip nhiu ph n c c hi c thc hin cc bin php trnh thai. Phong tc mi thuc l trong cc m ci, m ma nh hng khng nh ti t l ht thuc ca ngi Vit Nam. Qua mt nghin cu nh gi thc trng ht thuc l Vit Nam cho thy 58-69% s ngi c hi, cho rng nn mi thuc trong m ma, m ci. Cc can thip NCSK ch ti pht trin cng ng trong gio dc thay i hnh vi, v d thi ua xy dng cng ng khng ht thuc l, lng vn ho
2.3.5. Cp nh hng th nm - Yu t lut php

Cc lut, qui nh cho php hoc gii hn hoc nghim cm mt s hnh vi nguy hi cho sc khe. Trong mi trng lut php ny, con ngi kh c th thc hin nhng hnh vi m php lut cm, chnh iu ny to iu kin cho h thc hin v duy tr bn vng hnh vi c li cho sc khe ca chnh h v cng ng. V d: nghim cm bun bn cht ma tu, quy nh khng ht thuc l ni cng cng, khng x rc ba bi, quy nh i m bo him khi i xe my v eo dy bo him khi li xe t; x pht khi c nhn vi phm... Qua chng trnh GDSK, NCSK c th thc y thay i hnh vi thng qua cc can thip n mi trng x hi, chnh sch, lut php v pht trin k nng c nhn, to iu kin thun li cho c nhn hnh ng ci thin sc khe ca h. V d: chng trnh phng chng tc hi thuc l ng thi thc hin cc can thip nh: gio dc truyn thng nhm cung cp thng tin v tc hi ca thuc l, tng thu i vi mt hng thuc l, chnh sch kim sot thnh phn ha cht trong thuc l, cm qung co thuc l trn cc phng tin thng tin i chng, c cc quy nh c th v nhn mc, li cnh bo trn bao thuc l... Xc nh yu t nh hng ti s la chn hnh vi lnh mnh ca c nhn mt cch ton din, s gip h cn nhc v hnh ng thay i hnh vi. Cn b GDSK cn tn trng quan im, cch sng ca c nhn v c can thip thch hp. Cc l thuyt khoa hc hnh vi l c s c bn gii thch cho nhng thay i hnh vi sc khe.
3. QU TRNH THAY I HNH VI SC KHO 3.1. Mt s l thuyt v hnh vi c nhn

C nhiu hnh vi gp phn tng cng sc khe v bn thn nhng hnh vi ny thc y mi ngi tip tc thc hin. V vy, cn xc nh v khuyn khch ngi dn thc hin chng. Tri li, cng c nhiu hnh vi c hi cho sc khe. Thng thng th 35

hu qu c hi i vi sc khe ca mt hnh vi c th lm cho ngi dn t b hnh vi . Nhng c th do mt s l do c nhn, ngi dn vn tip tc lm nhng g nh h vn thng lm theo cch khng c li cho sc khe. Trc khi bt u nhng hot ng GDSK v NCSK, cn phi hiu bit thu o cc yu t tc ng n hnh vi, nhng kh khn c th gp phi, t chng ta s c cc gii php thch hp. Chng ta s xem xt mt s l thuyt gii thch hnh vi sc khe c nhn.
3.1.1. M hnh nim tin sc khe

M hnh nim tin sc khe (Rosenstock 1966 v Becker hiu chnh nm 1974) l mt trong nhng n lc nhm gii thch cc hnh vi sc khe. Nguyn l c bn ca m hnh ny gip cn b GDSK xc nh cch m c nhn nhn thc v sc khe ca h v nhn thc ny nh hng /thc y hnh vi ca ngi nh th no. Theo m hnh ny (S 2.4), cc c nhn s c nhiu kh nng thay i hnh vi c hi thc hin v duy tr hnh vi mi c li cho sc khe khi nhn thc c: Nguy c ca h vi mt bnh c th v s trm trng ca bnh ny. Sc khe ca h b e do bi bnh ny (do hnh vi ca h gy ra). S thu c nhiu li ch hn so vi nhng tr ngi c th gp phi khi thc hin hnh vi phng bnh (thay i hnh vi c hi). C nhiu thng tin v phng bnh, c s khuyn khch thay i hnh vi. V d: Nu p dng m hnh ny gio dc cc c nhn phng nga nhim HIV cc can thip truyn thng thay i hnh vi cn gip c nhn: + + + + + Nhn bit c h ang c nguy c nhim HIV. Tin rng hu qu ca nhim HIV l rt trm trng. Nhn c s khuyn khch ng h cho thay i hnh vi, v d cc thng tin t cc phng tin truyn thng i chng. Tin rng thc hnh hnh vi tnh dc an ton c kh nng gim bt nguy c ly nhim HIV. Nhn thc c li ch ca hnh ng gim nguy c s ln hn so vi cc chi ph v cc hn ch gy ra khc, v d trnh c nguy c nhim HIV s c li ch cho bn thn mnh hn l mt cht gim khoi cm tnh dc khi dng bao cao su, hoc cc phn ng tiu cc ca bn tnh... Xc nh c kh nng ca mnh thc hin thay i hnh vi v duy tr thc hnh tnh dc an ton.

M hnh nim tin sc khe c p dng hiu qu trong truyn thng thay i hnh vi, c bit trong cc chng trnh nh tim chng v kim tra sc khe nh k pht hin bnh giai on sm. Nhng n t hiu qu i vi cc hnh vi b nh hng bi nhiu yu t x hi nh lm dng ru v thuc l, nhng hnh vi lin quan n cc bnh mn tnh. V vy cn linh hot p dng cc m hnh l thuyt khc nhau trong cc can thip truyn thng thay i hnh vi. L thuyt ny c th rt hu dng 36

khi xem xt, cn nhc nhng thng tin lin quan n nhm ch cn phi thu thp trc khi pht trin chng trnh can thip.

Nhn thc c nhn

Cc yu t lm thay i

Kh nng thay i

Tui, gii, dn tc Tnh cch. Vn kinh t x hi. Hiu bit v bnh. Nhn thc v s nhy cm vi bnh X Nhn thc v s trm trng ca bnh X

Nhn thc li ch phng nga bnh tt so vi ro cn /tr ngi i vi vic thay i hnh vi.

Nhn thc v mi e da ca bnh X

Kh nng thay i hnh vi (kh nng thc hin hnh vi phng bnh)

ng lc cho hnh ng: - Gio dc - Cc triu chng bnh. - Chng kin t bn b, ngi thn - Thng tin t cc phng tin truyn thng i chng.

S 2.4. M hnh nim tin sc kho (Becker, 1974)

3.1.2. L thuyt v hnh ng hp l v hnh vi c lp k hoch (c d nh)

L thuyt hnh ng hp l c pht trin bi Ajzen v Fishbein (1980). L thuyt ny a ra mt cch gii thch v hnh vi c th c d on trc bi nh ca c nhn thc hin hnh vi . V d nh vic d on mt c nhn s chn mt chng trnh b thuc l hay gim bo nh th no ph thuc vo c nhn c d nh thay i khng, h c tin rng s thay i s c nhiu li ch cho sc kho ca h khng, h xc nh nhng chun mc chung nh th no, h c ngh rng nhng ngi xung quanh ng h vic h thay i hay khng (S 2.5). Theo l thuyt ny hnh vi sc khe ca c nhn l kt qu trc tip ca nhng hnh vi c d nh thc hin, ni khc i l hnh vi c nhn lp k hoch thc hin. C ba yu t nh hng n hnh vi d nh. l thi ca c nhn hng ti hnh ng, c im ca c nhn (i tng) quan tm ti hnh ng, v nhn thc 37

ca c nhn v kh nng kim sot hnh vi . Thi trong trng hp ny c xc nh bi nim tin cho rng kt qu mong c s xy ra nu hnh vi c th c thay i v kt qu ca s thay i s c li cho sc khe. c im ca c nhn trong trng hp ny lin quan ti nim tin ca mt ngi v iu m nhng ngi khc, nhng ngi xung quanh ngh h nn lm. Nhn thc c nhn v kh nng kim sot hnh vi l vic c nhn cm thy h c kh nng thc hin thay i hnh vi hay khng v thc hin hnh vi s c hiu qu nh d tnh khng? Ba yu t nh hng ny kt hp to nn hnh vi d nh. Hai tc gi Ajzen v Fishbein (1980) nhn thy rng con ngi khng lun ng x nht qun vi nhng d nh ca h. Kh nng d on hnh vi b nh hng bi tnh n nh ca nim tin c nhn. Mt ngi chc chn d nh iu chnh, thay i hnh vi c, thc hin v duy tr hnh vi mi nu ngi tin rng hnh vi mi s c li cho sc khe ca h. Theo l thuyt ny nu p lc x hi v nim tin mnh th hnh vi d nh thc hin s c chuyn thnh hnh vi tht s. L thuyt hnh ng hp l khc vi m hnh nim tin sc khe ch n t tm quan trng ca cc chun mc x hi nh mt nh hng chnh ln hnh vi. p lc x hi c th b nh hng t cc chun mc x hi, chun mc ca cng ng, nhm ng ng v nim tin ca nhng ngi quan trng khc nh cha m, ngi thn v bn b. S ng vin tun th cng vi p lc x hi t nhng nhm ngi c ngha quan trng i vi c nhn c th lm cho h c x theo cch m h tin rng cc c nhn hoc cc nhm khc ngh l ng. nh hng ca nhm ng ng c th rt mnh trong cc nhm nh nu cc thnh vin ca nhm mun thuc v nhm. V d nhng bn tr thng c xu hng ht thuc l nu trong nhm bn c ngi bn thn ht thuc hoc c ngi thn trong gia nh ht thuc.
Nim tin vo li ch ca s thay i nh gi v s thay i Nim tin vo nhng chun mc chung ng c tun th theo nhng ngi khc Yu t kim sot bn trong Yu t kim sot bn ngoi

Thi hng ti hnh vi Chun mc c nhn Hnh vi c d nh Hnh vi

Kim sot hnh vi

S 2.5. L thuyt ca hnh vi c d nh ca Ajzen, 1991 Ajzen pht trin thm m hnh hnh ng hp l v tr thnh l thuyt hnh ng hp l v hnh vi c d nh. Phn b sung thm chnh l phn yu t kim sot 38

hnh vi. Hnh vi c d nh ca c nhn cn chu nh hng ca kh nng kim sot hnh vi ca h. Yu t kim sot trong trng hp ny l: Yu t kim sot bn trong, c hiu l nim tin ca c nhn v trch nhim i vi sc khe ca h (control beliefs). Yu t kim sot bn ngoi, c hiu l nhng hnh ng ca h cn c th chu tc ng, nh hng bi cc yu t bn ngoi nh t nhng ngi khc c quyn lc, c hi, nh mnh hoc s may mn (perceived power).
3.1.3. L thuyt nhn thc x hi

L thuyt nhn thc x hi (Social cognitive theory) c xem l l thuyt hon chnh nht p dng gii thch cho thay i hnh vi. N cp ti vic xc nh hnh vi sc khe v phng php gip thay i hnh vi. Theo l thuyt nhn thc x hi: cc yu t x hi, cc yu t chnh sch, mi trng v x hi c th hnh thnh hnh vi ca con ngi. V d ti ni lm vic nu khng c quy nh khng ht thuc l th bn s cm thy bnh thng khi bn c hnh vi ht thuc. Ngc li nu c cc quy nh khng ht thuc l th khi bn ht thuc, v t nhiu bn s cm thy mnh ang vi phm quy nh ca cng s, v th gp phn hn ch hnh vi ht thuc ca bn. y cng l mi trng h tr cho vic b thuc l. Theo l thuyt nhn thc yu t x hi th hnh vi c nhn b nh hng rt nhiu bi mi trng x hi nh p lc t x hi, bn b v nhm. V vy cc nh truyn thng thay i hnh vi cn xem xt hnh vi c nhn trong ng cnh x hi, kinh t v gia nh khi lp mc tiu cho cc chng trnh sc khe. V d hnh vi dng chung bm kim tim nhng ngi tim chch ma ty b nh hng nhiu bi p lc ca nhm. N dng nh th hin tnh cng ng ca nhm nghin ht v gip nhau trong lc kh khn (Grund 1993). Hn na hnh vi ny cng b nh hng bi vn kinh t. Nhng ngi nghin cn kit tin v chi ph mua thuc. T cc can thip gio dc nn tp trung nng cao hiu bit cho cc ng ng vin, ng thi cung cp bm kim tim nhm h tr i tng v mt vt cht tng cng kh nng thay i hnh vi.
4. QU TRNH THAY I HNH VI V CAN THIP THCH HP

Qu trnh thay i hnh vi khng ging nhau i vi nhng c nhn khc nhau. C nhng ngi lun sn sng thay i cch ng x ca mnh khi h cm nhn s khng ph hp trong cch lm ca mnh, trong khi c nhng ngi rt chm hoc khng thay i hnh vi ca mnh. S thay i hnh vi thng xy ra theo hai hng: Thay i t nhin: Hnh vi thay i theo nhng s kin t nhin nh i khi chng ta c nhng thay i cch ng x ca mnh theo cng ng xung quanh m khng suy ngh nhiu v iu . Thay i c k hoch: i tng lp k hoch thay i hnh vi ca mnh nh tng bc gim dn s lng thuc ht hng ngy, ri tin ti b hn. 39

4.1. Cc giai on thay i hnh vi

Thay i hnh vi l mt qu trnh v thng thng chuyn dch qua nhiu giai on cc c nhn. L thuyt v s thay i hnh vi (Prochaska v DiClemente, 1984, 1986) gm nm giai on chnh (S 2.6).
Duy tr hnh vi lnh mnh

Thc hin s thay i Duy tr s thay i Cam kt, sn sng thay i Tr li hnh vi c D nh thay i Khng quan tm thay i hnh vi nguy c

S 2.6. Cc giai on thay i hnh vi (Naidoo J., Wills J., 2000)

4.1.1. Cha quan tm n thay i hnh vi

Trong giai on ny, c nhn bt u t ch cha bit, cha c kin thc, cha c d nh thay i hnh vi. C nhn cha c hiu bit v vn sc khe h ang mc, cha nhn thy nguy c tim tng ca hnh vi hay li sng hoc khng lnh mnh ca h. Sau khi tip cn cc ngun thng tin, i tng bit, c cung cp kin thc, hiu ra vn . Bin php tt nht lc ny l cung cp cc thng tin v nguy c ca bnh tt v ca li sng c nhn. Hnh thi thng ip nn tp trung to ra nhn thc ng n v s e da ca vn sc khe, ca hnh vi sc khe i vi i tng. Thng tin c th thuyt phc c nhn tin ti giai on tip theo. Chng ta cng c th a ra cc thng tin c nhn nhn thy mt c li nu thay i hnh vi. V d: s dng bao cao su trong quan h tnh dc s gim nguy c ly nhim HIV, s c li hn nhiu so vi nhng hn ch khng ng k ca bao cao su nh gim khoi cm v mt cht chi ph mua bao cao su. y l giai on kh khn nht cho cc nh truyn thng thay i hnh vi thuyt phc i tng hng n thay i hnh vi. 40

4.1.2. Quan tm thay i hnh vi

giai on ny, cc c nhn c cc thng tin v nguy c ca cc hnh vi khng lnh mnh v nhn thy cc li ch ca s thay i. i tng chp nhn thay i nhng h cha sn sng thay i v cn thiu mt s thng tin v s tr gip i n quyt nh. Truyn thng thay i hnh vi cn tip tc a thng tin v nguy c ca bnh tt vi hnh vi c nhn v thuyt phc cc c nhn thy c li ch ca vic thay i. Giai on ny cn c s h tr c nhn v mt tinh thn, vt cht, c bit s gip ca cc t chc on th, bn b to nn mi trng thun li gip cc c nhn thay i hnh vi.
4.1.3. Chun b thay i

C nhn c s quyt tm thay i hnh vi. H c nh thay i v chun b cho s thay i hnh vi ca mnh. Giai on ny i tng rt cn s gip v vt cht v tr gip v tinh thn, to iu kin thun li ca gia nh, bn b v x hi, ng thi cn gip i tng lp k hoch c th cho thay i. V d thay i hnh vi dng chung bm kim tim ngi tim chch ma ty th vic cung cp bm tim sch s h tr c nhn thay i hnh vi; hay vic cung cp bao cao su hng c nhn c thi quen dng bao cao su trong quan h tnh dc.
4.1.4. Hnh ng

C nhn sn sng thc hin vic thay i v thay i theo k hoch ca h. H th nghim thc hin hnh vi mi, ng thi nh gi nhng li ch m h nhn c t vic thc hin hnh vi mi. H c th gp phi mt s kh khn trong thi gian u thay i thi quen. Cn thng bo, t vn cho i tng mt s thay i, nhng tc dng ph khng mong mun c th xy ra cho c th trong thi gian u thay i thi quen v cch ng ph. Hng dn c nhn cn lm g vt qua mt s kh khn tm thi trong nhng ngy u thay i thi quen lu. Tng cng s tr gip, c nhng phn thng khch l ca gia nh, bn b khuyn khch i tng thc hin v tip tc duy tr bn vng. y l giai on kh khn cn c s gip ca nhng ngi lm GDSK v ngi thn c kinh nghim.
4.1.5. Duy tr hnh vi thay i

Cc c nhn thc hin v duy tr hnh vi mi c li cho sc khe ca mnh. Nu hnh vi mi ny din ra trong mi trng thun li th s c tnh n nh v bn vng. C nhn s nhn thc ng li ch ca s thay i v s tuyn truyn, vn ng ngi khc lm theo. Nu gp li mi trng c hoc nhng iu kin thun li cho s quay tr li hnh vi c th vic duy tr hnh vi mi d b ph v v i tng c th tr li nhng bc trc hoc ti din hnh vi c. Chng trnh gio dc cn cung cp s tr gip ca x hi, ca nhm ng ng v s ng vin ca gia nh, bn b c nhn duy tr hnh vi mi v li sng lnh mnh. iu quan trng nht giai on ny l chng ta cn gip c nhn khng quay tr li hnh vi c, duy tr mt mi trng thun li hnh vi mi bn vng. 41

V d: Ti nghin l mt vn c bit cc trng hp nghin ma ty, ru, thuc l. V vy hn ch nhng mi trng d lm cho i tng tr li thi quen l iu cn lu . Nn khuyn c nhn ang cai nghin thuc l khng nn n nhng ni c nhiu khi thuc; trnh nhng ngi ang ht thuc, t chi kho khi bn b mi thuc. Trong thi gian cai nghin cn trnh cc trng thi bt thng v tnh cm, cm xc bi cc trng thi bun ru, tht vng d y c nhn nghin tr li. S dng s khuyn khch, nhc nh ca bn b, gia nh nhc nh c nhn khi c nh ti nghin. Hiu bit su sc cc bc thay i hnh vi ca i tng s gip chng ta c nhng can thip ph hp, hiu qu gip cho ngi dn thay i v duy tr hnh vi mi, c li cho sc khe. Trong mi giai on c th, cc gii php can thip tng ng s em li hiu qu cao hn so vi can thip chung. V d, mt ngi ht thuc l trong giai on th b thuc s thy rng nhng thng tin v tc hi ca ht thuc l khng cn hp dn h na, tuy nhin nhng thng tin v mt s kh khn, nhng phn ng ph c th xy ra khi b thuc v cch ng ph s l nhng iu anh ta mong mun. gip i tng thay i hnh vi, ngi lm cng tc GDSK cn: Chun b cc cu hi tm hiu vn ca i tng; xc nh i tng ang giai on no ca qu trnh thay i hnh vi c cc can thip thch hp. i tng sn sng thay i hnh vi cha? Phi lm nhng g gip i tng tng giai on ca qu trnh thay i; cn h tr nhng g thc y c nhn thay i hnh vi. Gip c nhn ng ph vi cc kh khn khng quay li hnh vi, thi quen c. Thc t cc giai on thay i khng phi lc no cng i qua trnh t cc bc nh vy. Hnh vi thay i ng vi giai on sau vn c th quay v tnh trng ban u nu khng c nhng iu kin h tr thch hp. Nhng can thip nhm thay i hnh vi sc khe ca i tng ph hp vi tng giai on c th s t kt qu hn nhng can thip khng da trn vic xc nh r hnh vi ca i tng ang giai on no. Thc t l thuyt cc giai on thay i hnh vi ny c p dng thnh cng cho nhiu can thip thay i hnh vi sc khe khc nhau nh: b ht thuc, cai nghin ma tu, gim cn nng, iu chnh ch n ung nhiu cht bo, hot ng tnh dc an ton, tp th dc thng xuyn (xem thm bng 2.3) Bng 2.3. V d v p dng l thuyt thay i hnh vi trong vic thc y gim cn nhng ngi bo ph (Don Nutbeam v Elizabeth Harris, 2004)
Cc giai on thay i Tin d nh D nh Qu trnh thay i Nng cao nhn thc Nhn thc ng v li ch ca s thay i Hnh ng ca ngi GDSK Trao i vi ngi bnh v vn bo ph v kh nng lm gim cn gii quyt vn . Trao i vi ngi bnh v nhng li ch tim tng h c c khi gim cn

42

Chun b

Xc nh cc yu t cn tr Chng trnh hnh ng thay i Duy tr thc hin v tip tc h tr

Gip ngi bnh xc nh cc kh khn, cn tr c th gp phi v cch gii quyt; nhn mnh n nhng li ch. Lp k hoch hnh ng, nhng bi tp c th gim cn, theo di st ngi bnh. Theo di, h tr thng xuyn; trao i vi ngi bnh v kh nng ti tng cn.

Hnh ng Duy tr

Nhng l thuyt nu trn cho thy kin thc, thi , nim tin, chun mc v gi tr x hi c s lin quan, kt hp cht ch trong mi con ngi nh hng, hnh thnh hnh vi ci thin, tng cng sc khe. Hnh vi c hnh thnh bi nhiu yu t v khi thay i c th chuyn bin qua nhiu giai on. Hnh vi cn c nhn nhn mt cch tng th v phn tch r trn tng nhm i tng lm c s cho vic thit k nhng chng trnh can thip thch hp v hiu qu.
4.2. Cc iu kin tin quyt thay i hnh vi

Theo quan im mi, hnh vi c nhn b nh hng bi rt nhiu yu t. V vy gio dc truyn thng thay i hnh vi cn c nhn nhn rng hn v mt tc ng tm l x hi v mi trng. Qua thc t, t nhng trng hp thay i hnh vi gi rng thay i hnh vi cn phi c nhng iu kin ti thiu thc hin (Jannie Naidoo v Jane Wills, 2000).
4.2.1. Vic thay i phi do c nhn t nguyn

Trc ht c nhn phi c ng c mun thay i hnh vi. Nu chng ta p buc i tng thay i hnh vi khi h cha nhn thy li ch ca vic thay i v tc hi ca hnh vi khng lnh mnh ca h th vic thay i ch c tnh tm thi. Nhng ngi lm truyn thng thay i hnh vi cn a ra cc thng ip r rng, c tnh thuyt phc i tng nhn thy nguy c i vi bn thn h v t nguyn hng ti thay i.
4.2.2. Hnh vi cn thay i phi c tnh ni bt, tc hi ti sc khe

Hu ht cc hnh vi lin quan n sc khe c hnh thnh trong cuc sng hng ngy nh mt thi quen m c nhn t suy ngh hoc n. V d hnh vi ht thuc l, ung ru, n ung khng khu phn dinh dng c xem nh thi quen bnh thng ca con ngi. thay i, hnh vi ang tn ti ny cn c lm r l c hi v gim s chp nhn ca nhng ngi khc v hnh vi ny. V d: mt ngi ht thuc chun b sng cng mt ngi khng ht thuc th hnh vi ht thuc c xem xt li; ci cht ca mt ngi h hng v ung th v c th lm cho mt ph n trong gia nh lp tc i khm sng lc.
4.2.3. Cc hnh vi thay i phi c duy tr theo thi gian

Cc hnh vi mi phi tr thnh thng xuyn, c duy tr hng ngy trong cuc sng. S d dng quay li hnh vi c nu vic thc hin hnh vi mi gp nhiu kh khn. V vy truyn thng thay i hnh vi cn ch gi cc hnh ng n gin 43

c nhn c th thc hin c v d thc hin. V d tng cc hot ng th cht bng cch i b, tp th dc ti nh s d thc hin hn l tp cc trung tm th hnh.
4.2.4. S thay i hnh vi khng qu gy kh khn cho c nhn

Vic thay i c hnh vi khng lm c nhn phi vt qu sc v kh nng ca mnh. Vic thay i hnh vi khng lm o ln cuc sng, cng vic thng l ca c nhn. Tuy nhin cng nn i tng xc nh cc cch ng ph thay i hnh vi c theo cch thch hp ca h nhm c c hnh vi mi.
4.2.5. Phi c s tr gip x hi

S tr gip ca x hi l rt quan trng bi vic thay i ca c nhn c th l thay i v mt tm l v h cn tr gip ca bn b, gia nh, x hi. S quan tm ca nhng ngi xung quanh s khuyn khch c nhn thay i hnh vi v duy tr hnh vi thay i. V vy song song vi vic truyn thng, gio dc thay i hnh vi, chng ta cn lm tt cc chng trnh tr gip x hi khuyn khch, ng vin c nhn thay i hnh vi v duy tr hnh vi thay i.
Cu hi tho lun

Nu r cc yu t nh hng n sc khe: Xc nh mt vn sc khe, xc nh cc yu t nh hng n vn sc khe ny, tp trung phn tch nhng yu t nh hng n hnh vi sc khe trong vn sc khe xc nh. Phn tch cc yu t nh hng n hnh vi sc khe da trn mt s vn v hnh vi sc khe nh: i m bo him khi i xe my; ht thuc l; s dng bao cao su trong quan h tnh dc; tp th dc hng ngy...
TI LIU THAM KHO
1. Egger, Spark, Lawson, Donovan, (1999). Health Promotion Strategies and

Method, p: 9-12.
2. Glanz, K., Lewis, F.M., and Rimer, B.K. (1997). Health Behavior and Health

Education: Theory, Research, and Practice (2nd edition). San Francisco, CA: Jossey-Bass Publishers.
3. Jenie Naidoo, Jane Wills (2000). Health Promotion, Foundations for

Practice. p: 3-48.
4. John Kemm, Ann Close (1995). Health Promotion - Theory and Practice, p: 3. 5. WHO (1994). Health Promotion and Community action for Health in

developing countries. p: 1-6.

6. John Walley, John Wright, John Huble (2001). Public Health, An action

guide to Improving Health in Developing Countries. Oxford University Press, p: 141-152. 44

45

Bi 3

CC PHNG THC TIP CN V M HNH NNG CAO SC KHO

MC TIU
1. M t c cc cch tip cn trong nng cao sc khe. 2. Trnh by c cc m hnh nng cao sc khe. 1. CC PHNG THC TIP CN NNG CAO SC KHO

Trong cc bi trc chng ta xem xt cc khi nim v sc khe, GDSK v NCSK. Chnh tnh a dng ca cc cc khi nim v sc khe, cc yu t tc ng n sc khe v cc ch s o lng sc khe dn n vic hnh thnh cc cch tip cn khc nhau p dng trong NCSK. Hin nay c nm cch tip cn chnh ang c p dng trong NCSK, l: Tip cn Y t (bao gm iu tr v d phng). Tip cn Thay i hnh vi. Tip cn Gio dc sc khe. Tip cn Nng cao kh nng lm ch v sc khe/Trao quyn v sc kho. Tip cn Vn ng to ra mi trng x hi thun li. Cc phng thc tip cn ny s c xem xt c th v mc ch, phng php v phng tin nh gi trong ni dung bi ny. Mc d mi cch tip cn NCSK xut pht t cc kha cnh v gc khc nhau, chng u nhm cc mc ch c bn sau: Phng nga v iu tr bnh tt. m bo cung cp y thng tin ngi dn c th t la chn cc gii php bo v v NCSK ph hp. To iu kin gip ngi dn c k nng v nim tin t chm sc sc khe tt hn. To ra mi trng x hi vi cc chnh sch thun li cho vic la chn cc gii php NCSK. V c bn khi gii quyt mt vn sc khe, vic xc nh cch tip cn kh thi chnh l qu trnh m t, phn tch vn tm ra cc nguyn nhn, cc yu t quyt nh hoc cc yu t nguy c trc tip. Kt qu ca vic phn tch vn sc kho s lm c s la chn phng thc tip cn gii quyt thch hp. 46

1.1. Tip cn y t 1.1.1. Mc tiu

Tip cn ny bao gm cc hot ng nhm lm gim t l mc bnh v t l t vong. i tng ca cc hot ng ny l ton b qun th v nhng nhm nguy c cao. Mc ch cui cng ca cch tip cn ny l nhm tm ra cc bin php d phng ngn chn s pht trin ca bnh v cc trng hp t vong. Bin php ny thng c m t di ba cp can thip: D phng cp I: Ngn cn s xut hin ca bnh tt bng cch gio dc sc khe, tim chng, v d: khuyn khch khng ht thuc l, khng n thc n khng hp v sinh... D phng cp II: Ngn cn s tin trin ca bnh thng qua khm sng lc v cc bin php chn on sm khc, v d sng lc pht hin bnh lao, ung th v... D phng cp III: Gim thiu hu qu ca bnh tt v ngn nga bnh ti pht nh phc hi sc khe, gio dc bnh nhn, liu php gim au... Hin nay tip cn y t, c bit l d phng cp I v cp II c p dng kh ph bin v c nh gi cao nh vic s dng cc phng php khoa hc nh nghin cu bnh dch. Hn na vic ngn nga v pht hin bnh sm thng t tn km hn nhiu so vi vic iu tr cho nhng ngi mc bnh. Tip cn y t thng mang tnh chuyn mn cao v mang tnh p t t bn ngoi. y vai tr ca cc chuyn gia y t, nhng ngi c kin thc chuyn mn v cng quan trng v ng vai tr ch o. Nh thc hin bin php ny chng ta thu c nhng thnh tu ng k v sc khe. V d nh vic loi tr bnh u ma trn th gii v thanh ton bnh bi lit Vit Nam l nh kt qu ca chng trnh tim chng. Tuy nhin v bn cht, tip cn y t c xy dng da trn khi nim c bnh hay khng c bnh. Cch tip cn ny nghing v cha bnh, phng bnh c th m khng nhm mc ch NCSK v do vy b qua cc kha cnh mi trng v x hi ca sc khe. Khi x hi pht trin, y t khng ch phc v mc ch phng nga bnh tt m cn ch trng n vic nng cao cht lng cuc sng. Ngoi ra, cch tip cn ny cn dn n tnh trng ph thuc qu nhiu vo y hc khin ngi bnh tr nn th ng, khng tch cc trong vic hnh ng v quyt nh sc khe ca chnh mnh.
1.1.2. Cc phng php

Nguyn tc c bn ca cc dch v d phng nh tim phng hay khm sng lc l tp trung phn ln ngun lc vo cc nhm nguy c cao mt iu kin nht nh. Trong khi vic tim chng i hi mt liu lng nht nh t hiu qu mong mun th vic khm sng lc ch c p dng i vi mt s nhm nht nh. V d, i vi n gii tui t 20-64 cn phi c khm sng lc ung th c t cung 3 nm mt ln. Tim phng cc bnh nhim khun nh bch hu, ho g cn dng liu quy nh mi c tc dng. 47

 liu php d phng t hiu qu, vn sc khe cng nh i tng ch cn p ng mt s tiu chun nht nh. V d cng tc khm sng lc t hiu qu cao, bnh c sng lc cn p ng mt s tiu ch: Cn bnh cn phi c thi k tin lm sng ko di khng b st cc triu chng bnh. iu tr sm s mang li kt qu tt hn. Xt nghim s dng cn c nhy cao, ngha l cn phi pht hin ra tt c nhng ngi mc bnh (t l m tnh gi thp). Xt nghim s dng cn c c hiu cao, ngha l ch pht hin nhng ngi mc bnh (t l dng tnh gi thp). Cn phi hiu qu, c ngha l vi mt s xt nghim nht nh phi pht hin ra mt s ng k cc trng hp dng tnh. Cc bin php y t cng cn da trn c s cc bng chng dch t hc. N cng i hi mt c s h tng m bo kh nng cung cp cc dch v ny ti ngi s dng. C s h tng y bao gm nhn lc, trang thit b, h thng qun l thng tin xc nh xem ai l i tng s dng dch v. Bn cnh vic m bo cung cp y cc dch v ny ch c hiu qu khi ngi dn tch cc tham gia chng trnh. R rng bin php y t l mt qu trnh phc tp v ph thuc rt nhiu vo s ch o t tuyn trn v cc chng trnh y t quc gia.
1.1.3. nh gi

V nguyn tc, vic nh gi hiu qu ca tip cn y t phi da trn vic gim t l bnh tt v t l t vong ca bnh. y l mt qu trnh lu di v khng phi lc no cng thc hin c. Hin nay ngi ta phi da trn cc ch s gin tip nh s ngi s dng dch v. Mc d c mt mi tng quan cht ch gia kh nng tip cn dch v v vic gim t l mc bnh nhng cng cn phi thn trng khi ch da trn ch s ny. V d vo nm 1974 Anh, 80% tr em c tim phng ho g. Theo cc phng tin thng tin i chng v tnh an ton ca vaccin, t l tim phng ho g n nm 1987 mi t n 80%. Cc t bnh dch ho g nm 1977-1979 v 1981-1983 cho thy vic tim phng gp phn lm gim t l mc bnh ny. Tuy nhin, t l t vong v bnh ho g nhn chung gim trc khi vaccin c s dng vo nm 1957 cho thy rng c th chnh iu kin dinh dng, iu kin sng v chm sc y t tt hn cng ng vai tr quan trng vo vic gim t l mc bnh.
1.2. Tip cn thay i hnh vi 1.2.1. Mc tiu

Mi tng quan gia thay i hnh vi v tnh trng sc khe l c s a ra cc can thip tc ng n hnh vi. Tip cn ny nhm khuyn khch c nhn chp 48

nhn v thc hin nhng hnh vi lnh mnh, nhng hnh vi c xem l yu t quyt nh i vi vic NCSK. Vic a ra cc quyt nh c lin quan n sc khe l mt qu trnh rt phc tp, n ch t c hiu qu khi c nhn chun b sn sng cho vic thay i hnh vi. Vic thc hin cc hot ng nhm tc ng v thay i hnh vi t lu l mt phn quan trng trong chng trnh gio dc sc khe. y l cch tip cn rt ph bin. Bng cch thay i li sng, con ngi c th ci thin mt cch ng k sc khe ca mnh. Tng t nu h khng c trch nhim bo v sc khe ca mnh th h phi chu trch nhim v vic . Khi xem xt ti sao mt ngi khng chu thc hin cc hnh vi c li cho sc khe ca chnh h, chng ta cn tm hiu nguyn nhn vn mt cch ton din. V d ti sao h khng chu n ung mt cch hp l. C rt nhiu yu t c th gy ra tnh trng ny nh thiu kin thc, khng bit ch bin thc n, khng c tin, s thch ca gia nh, hay ti a phng khng c cc thc phm cn thit v ph hp... Cng cn lu rng hnh vi sc khe khng tch ri cc hnh vi khc v tt c cc hnh vi din ra hnh ngy nh n, ng, lm vic, th thao suy cho cng u tc ng t nhiu n sc khe. Vic tm hiu nguyn nhn su xa cc hnh vi c nhn l cha kha gip h gii quyt vn . Bn cnh c mt mi quan h phc tp gia hnh vi c nhn v cc yu t mi trng v x hi. Hnh vi c th l kt qu ca s p ng i vi iu kin sng v cc nguyn nhn dn n iu kin nh tht nghip, ngho i, chng c th nm ngoi kh nng kim sot ca c nhn. Thay i hnh vi ca c nhn c th b hn ch hoc thc y bi h thng x hi m h l mt thnh vin.
1.2.2. Phng php

Chin dch vn ng khng ht thuc l, khuyn khch rn luyn th lc l cc v d in hnh ca phng php ny. Cch tip cn ny nhm vo tng c nhn mc d vic tip cn h c th c thc hin thng qua cc phng tin truyn thng i chng hay t vn trc tip.
1.2.3. nh gi

nh gi cc can thip thay i hnh vi tng chng n gin bng cch tr li cu hi hnh vi sc khe ca c nhn c thay i sau can thip khng? Tuy nhin, qu trnh thay i hnh vi thng din ra trong mt thi gian di v thng thng kh xc nh c mt cch r rng thay i no l do can thip tc ng, thay i no do cc yu t khc gy ra.
1.3. Tip cn gio dc sc khe 1.3.1. Mc tiu

Mc tiu ca cch tip cn ny l cung cp kin thc, thng tin v pht trin nhng k nng cn thit con ngi c th la chn hnh vi sc khe ca mnh. Cn phi phn bit tip cn hay bin php gio dc vi bin php thay i hnh vi ch bin php thay i hnh vi khng nhm thuyt phc hoc khuyn khch thay i theo mt chiu hng c th no. Trong khi , vic gio dc sc khe l nhm t mt kt qu nht nh. 49

Tip cn gio dc sc khe c da trn mt lot cc gi thit v mi quan h gia kin thc v hnh vi: l bng cch tng cng kin thc v hiu bit s dn n thay i v thi v t c th dn n thay i v hnh vi.
1.3.2. Cc phng php

Cc l thuyt tm l cho rng qu trnh hc tp tip thu tri thc lin quan n ba yu t: Nhn thc (thng tin v s hiu bit). Tc ng (thi v tnh cm). Hnh vi (cc k nng). Tip cn gio dc NCSK s cung cp thng tin gip i tng la chn hnh vi sc khe ca mnh. Phng php ny c th c thc hin bng vic pht t ri, hng dn, bng rn, p phch. ng thi cng to iu kin cho i tng chia s nhu cu sc khe ca mnh. C th gio dc theo tng nhm hoc cho tng ngi. Cc chng trnh gio dc cng gip pht huy kh nng a ra quyt nh ca cc khch hng thng qua cc vai din. i tng c th ng vai hoc rn luyn cch ng x trong cc tnh hung thc t ca cuc sng hng ngy. Cc chng trnh gio dc thng c hng dn bi mt gio vin hoc mt ngi hng dn mc d vn tho lun c th do i tng quyt nh. Cc can thip gio dc i hi ngi lm cng tc NCSK phi hiu cc nguyn tc hc tp ca c ngi ln v tr em cng nh cc yu t thc y hoc gy cn tr vic hc tp ca h.
1.3.3. nh gi

nh gi vic tng cng kin thc, hiu bit l cng vic tng i d dng. Gio dc sc khe thng qua cc chin dch truyn thng tin i chng, gio dc tng ngi v gio dc theo tng lp hc u mang li thnh cng trong vic tng cng thng tin v cc vn sc khe, hoc hiu bit v cc yu t nguy c i vi mt vn sc khe. Nhng ch c thng tin khng th cha gip i tng thay i hnh vi ca h.
1.4. Tip cn trao quyn v sc khe /nng cao kh nng lm ch v sc kho 1.4.1. Cc mc tiu

WHO khng nh NCSK l to iu kin cho ngi dn tng cng kh nng kim sot c cuc sng ca chnh mnh. Trao quyn c s dng m t cch tip cn nhm tng cng kh nng ca ngi dn trong vic thay i hon cnh thc t ca chnh mnh. Cch tip cn ny gip con ngi xc nh c cc mi quan tm ca h, c c cc k nng v nim tin hnh ng v sc khe ca mnh. y l phng php NCSK duy nht bt ngun t chnh mi c nhn i hi ngi lm cng tc NCSK c nhiu k nng khc nhau. Thay v ng vai tr l chuyn gia nh cc 50

bin php khc, ngi lm cng tc sc khe y tr thnh ngi hng dn, c chc nng h tr, khi xng vn , khuyn khch mi ngi thc hin v dn dn rt lui khi t kt qu mong mun. Khi ni v trao quyn, chng ta cn phi phn bit gia trao quyn cho c nhn v trao quyn cho cng ng. Trao quyn cho c nhn c s dng trong mt s trng hp nhm m t cc bin php tng cng sc khe da trn vic t vn, ly ngi dn c nhu cu v sc khe (khch hng) lm trung tm nhm tng cng kh nng kim sot cuc sng ca chnh h. i vi nhng ngi c trao quyn, h cn phi: Nhn bit v hiu c tnh trng hn ch v kh nng thc hin cc hnh vi c li cho sc khe ca mnh. Nhn bit r v tnh trng ca mnh t c mong mun thay i. Cm thy c kh nng thay i tnh hnh thng qua vic c cung cp thng tin, h tr v trang b cc k nng sng.
1.4.2. Cc phng php

Cc ni dung chnh ca phng php ny c th rt quen thuc i vi nhiu y t chm sc bnh nhn, vi gio vin lm cng tc nng cao tnh t gic ca hc sinh v i vi nhng ngi lm cng tc sc khe khc. Chng c th mang cc tn gi khc nhau nh phng php ly khch hng lm trung tm, h tr hay t chm sc nhng v bn cht l nh nhau. Vai tr ca ngi lm cng tc NCSK l gip i tng ch xc nh c nhng vn sc khe v cc chiu hng thay i. Pht trin cng ng trong y t cng cng l mt phng php tng t trao quyn cho cc nhm bng cch xc nh nhng vn ca h, cng lm vic vi h lp chng trnh hnh ng nhm gii quyt vn sc khe. Cng tc pht trin cng ng l mt cng vic mt nhiu thi gian, v nhng ngi lm cng tc y t cn xc nh u tin cho nhng vic chnh.
1.4.3. nh gi

nh gi trong cch tip cn ny l mt vic lm tng i kh khn, mt phn l do qu trnh trao quyn lm ch v thit lp mng li NCSK c bn l mt qu trnh lu di. Do kh c th chc chn rng cc thay i c c l do can thip ny ch khng phi do cc yu t khc to nn. Ngoi ra, kt qu tch cc ca mt bin php nh vy c th rt m h v kh xc nh, c bit l khi so snh chng vi nhng kt qu ca cc bin php khc, nh cc mc tiu hoc thay i v hnh vi m c th xc nh c s lng ca chng. nh gi c th c da trn mc thc hin c mc tiu c th (nh gi kt qu) v mc m nhm t c v vic thc hin cc hnh ng mong mun (nh gi qu trnh).

51

1.5. Vn ng to ra mi trng kinh t - x hi thun li cho cc hot ng nng cao sc khe 1.5.1. Mc tiu

Thy r tm quan trng ca mi trng kinh t - x hi trong vic quyt nh sc khe, cch tip cn ny ch trng vn v chnh sch v mi trng nhm mc ch c c nhng thay i trong mi trng t nhin, mi trng kinh t x hi nhm to ra nhng thun li cho cc hot ng NCSK. Bin php ny nhn mnh lm sao cho vic la chn cc hnh vi c li cho sc khe tr thnh mt vic lm n gin hn, thc tin hn. Cc bin php c li cho sc khe lun lun c sn nhng vn l phi lm cho n tr thnh hin thc v kh thi v hu ht mi ngi u mong mun c nhiu thay i v chi ph, tnh sn c hoc kh nng tip cn vi cc dch v v sc khe.
1.5.2. Cc phng php

Hot ng trong tip cn ny i hi ngi lm cng tc NCSK phi c nhng k nng vn ng cn thit nh: lp k hoch chin lc NCSK, vn ng hnh lang, thng thuyt m phn... Chin lc chm sc v bo v sc khe nhn dn giai on 2001-2010 vi mc tiu chung l phn u mi ngi dn c hng cc dch v CSSKB, c iu kin tip cn v s dng cc dch v y t c cht lng; mi ngi u c sng trong cng ng an ton, pht trin tt v th cht v tinh thn, gim t l mc bnh, nng cao th lc, tng th lc v pht trin ging ni. Nhiu gii php ra t c mc tiu ny trong c gii php y mnh cng tc y t d phng, nng cao sc khe. y chnh l kt qu ca qu trnh vn ng lu di cho cng tc chm sc sc khe nhn dn ca ngnh y t. Chin lc ny to mi trng chnh sch thun li cho vic trin khai cc hot ng NCSK tt c cc cp.
1.5.3. nh gi

nh gi cc hot ng ca cch tip cn ny bao gm o lng cc kt qu nh thay i v lut, qui nh, chnh sch hay t chc nhm NCSK, v d xy dng khu vc vui chi an ton cho tr em, cm qung co thuc l trn cc phng tin thng tin i chng, cm ht thuc nhng ni cng cng... Nhng kt qu ny thng l ca nhng qu trnh phc tp v din ra trong thi gian di, do vy cng kh chng minh c mi quan h trc tip ca chng vi cc can thip NCSK nht nh. Nm cch tip cn khc nhau ca NCSK trong thc t i khi c ranh gii khng tht r rng. Tuy nhin, nhng tip cn ny v bn cht l khc nhau. Chng bao hm cc gi thit khc nhau c lin quan n bn cht ca thay i sc khe. Cc phng php can thip thch hp, cc k nng cn thit v cc phng tin nh gi u khc nhau. Trong thc t, thc hin nhng hot ng ca cc chng trnh NCSK, cc tip cn thng khng tch ri, ring r m ngi lm cng tc NCSK lun lng ghp, phi hp hi ho t c mc tiu tng th ca chng trnh. 52

Bng 3.1. Cc cch tip cn NCSK thng qua v d v hnh vi n ung lnh mnh
Tip cn Y t Mc tiu Xc nh nhng ngi c nguy c v sc khe lin quan n hnh vi n ung Phng php Khm bnh do bc s thc hin (o ch s pht trin c th BMI) Mi quan h CBYTkhch hng CBYT ng vai tr ch ng Khch hng ng vai tr th ng, tun theo ch dn ca cn b y t. CBYT ng vai tr ch ng Khch hng ng vai tr ph thuc

Thay i hnh vi

Khuyn khch cc c nhn c trch nhim vi sc khe ca chnh mnh v la chn cc hnh vi lnh mnh c li cho sc khe Nng cao kin thc v k nng m bo mt cuc sng lnh mnh

Thuyt phc thng qua t vn, cung cp thng tin, cc chin dch truyn thng

Gio dc sc khe

Cung cp thng tin Tm hiu kin thc thi thng qua lm vic vi nhm nh Pht trin k nng

CBYT ng vai tr ch ng. Khch hng c th tham gia tho lun v a ra quyt nh

Trao quyn/ nng cao kh nng lm ch v sc khe

Lm vic vi c nhn hay cng ng p ng nhu cu h a ra

Vn ng Thng thuyt Thit lp mng li c s To iu kin thun li

Ngi lm cng tc NCSK ng vai tr h tr. Khch hng c trao quyn lm ch Mang tnh p t t trn xung i hi c s cam kt ca cc nh lm chnh sch v cng ng

Vn ng to mi trng x hi thun li cho nng cao sc khe

Nhm gii quyt cc vn v cng bng trong chm sc sc khe gia cc tng lp x hi, gii, dn tc, hay khu vc a l

Xy dng chnh sch, php ch v y t cng cng (quy nh dn nhn mc ln thc phm) Vn ng hnh lang Kim sot ti chnh (tr cp cho nng dn sn xut thc phm sch)

2. CC M HNH NNG CAO SC KHO

Cc phng thc tip cn NCSK hay cn c th gi l nhng bin php NCSK trn y v c bn l nhm m t nhng hot ng ngi lm cng tc NCSK tin hnh v ngi ta c th thc hin bin php ny hoc bin php khc ty thuc vo tnh hung c th. Vic xy dng mt m hnh thc hnh xc nh cc loi hnh NCSK l rt cn thit. Thc t, mt m hnh chm sc sc khe thng thng bao gm cc yu t ch yu nh khch hng, cc mc tiu, hot ng v kt qu. Cc m hnh NCSK c nhiu mc ch khc nhau. Chng khng phi ch l m hnh hng dn 53

hnh ng m c th h tr khi qut ha hoc s ha phm vi NCSK; xem xt hoc phn tch cc hot ng ang trin khai; lp k hoch v v biu cc kh nng can thip. Vic s dng m hnh trong tip cn NCSK l rt cn thit v iu khuyn khch vic t duy theo mt khung l thuyt chung, t a ra cc chin lc v phng php hnh ng hp l v c c s khoa hc. iu ny cng gip sp xp u tin hoc t nhiu xc nh c cc hnh thc can thip ph hp. Cc m hnh NCSK ngy cng xut hin nhiu vi ni dung an xen nhau nhng thng khng c s thng nht v thut ng hoc cc tiu chun c bn. Nhng tranh lun v cc m hnh NCSK c th c nh gi nh l mt du hiu ng khch l ca mi quan tm v mt hc thut nhm pht trin mt c s l thuyt ng n hnh ng.
2.1. M hnh ca Caplan v Holland (1990)

M hnh ny a ra bn phng thc c bn dng trong NCSK c xp thnh hai nhm (S 3.1). Nhm th nht lin quan n bn cht ca kin thc. Kin thc c xem xt l mt chui lin tc bao gm t cc bin php ch quan n s hiu bit ri n cc bin php khch quan. Cc l lun da trn c s y hc (nh sc khe l ng ngha vi khng bnh tt) ch l mt phn ca m hnh ny. M hnh ny ch n cch l gii ca nhng ngi khng c chuyn mn y t v khi nim sc khe v ngha ca sc khe i vi h. Nhm th hai c lin quan n nhng gi thit v bn cht c cu ca x hi. Nhng gi thit ny gii hn trong phm vi t cc l thuyt v thay i c bn v c cu x hi n cc l thuyt v lut l x hi. Mi gc mt phn t trong S 3.1 m t mt cch tip cn trong vic nghin cu v sc khe v thc hnh NCSK. Cc cch tip cn ny khng hon ton c lp vi nhau. C nhng tnh hung khi chng ta thc hin mt bc hay mt cch tip cn ny l bc khi u cho vic chp nhn mt hay nhiu cch tip cn khc. Mi cch tip cn phi hp cc gi thuyt v trit l khc nhau v x hi, khi nim sc khe v cc nguyn nhn gy bnh.
1. Quan im truyn thng /c in c lin quan n cc bin php y t v

bin php thay i hnh vi. Kin thc xut pht t pha cc nh chuyn mn v im mu cht l cung cp thng tin nhm thay i hnh vi.
2. Quan im nhn vn c lin quan n bin php gio dc. Gio dc sc

khe gip cho cc c nhn c th s dng cc k nng v phng php ca ring mnh s dng ti a cc iu kin sng m theo h l lnh mnh.
3. Quan im nhn vn cp tin c lin quan n bin php trao quyn. y

NCSK ch trng n vic tng cng nhn thc, v mt phn ca ni dung ny l tp trung vo vic khm ph nhng phn ng c nhn i vi cc vn v sc khe. Cng vi iu ny, cc c nhn c khuyn khch hnh thnh nn cc mng li x hi, kinh t, t chc to iu kin thun li cho vic NCSK. 54

4. Quan im c cu x hi cp tin khng nh rng s bt cng bng x hi

l nguyn nhn su xa ca cc vn v sc khe, v vai tr ca nng cao sc khe l nhm tc ng vo mi quan h gia sc khe v s bt cng bng trong x hi.

Thay i c bn
Quan im nhn vn cp tin Quan nim ton din v sc khe t mang tnh chuyn mn Mng li t h tr

Bn cht x hi

Quan im c cu x hi cp tin Sc khe phn nh nhng bt bnh ng x hi Nhu cu ci cch v c cu t chc XH

Ch quan

Khch quan

Quan im nhn vn Quan nim ton din v sc khe Nhm mc ch nng cao nhn thc v pht trin bn thn Do i tng quyt nh

Bn cht tri thc

Quan im truyn thng Sc khe ng ngha vi khng c bnh tt Mc ch l thay i hnh vi Chuyn gia y t quyt nh Lut l x hi

S 3.1. Bn phng thc c bn ca NCSK

(Naidoo J., 2000, Health Promotion)

2.2. M hnh ca Beattie (1991)

Beattie a ra mt phng php phn tch theo khung l thuyt v NCSK ca cc cch tip cn khc nhau. ng cho rng c bn chin lc NCSK (S 3.2). Tt c u xut pht t cc hot ng can thip, c th mang tnh chuyn quyn/p t (t trn xung v theo s hng dn ca chuyn gia) hay trn c s tha thun (t di ln v nh gi cao quyn t ch c nhn). Trong nhiu trng hp, NCSK bao gm vic hng dn v cung cp thng tin do cc cn b y t quyt nh v thc hin. 55

Tng t, cng tc chnh sch cng c cc chuyn gia hng dn v vic xc nh u tin l da trn cc s liu dch t hc. Ngoi ra NCSK c th bao gm cc can thip tp trung vo tng c nhn hay tp th, hoc tp trung gii quyt cn nguyn ca vn . Bn chin lc chnh nng cao sc khe trong cc phng php ca Beattie bao gm:
1. Thuyt phc v sc khe: L nhng can thip do chuyn gia y t thc hin

nhm vo c nhn. V d ngi lm cng tc CSSKB khuyn khch mt ph n mang thai ngng ht thuc, vn ng ph n c thai i khm thai ba ln trc sinh v tim vaccin phng un vn...
2. Hnh ng mang tnh lut php: L nhng can thip do chuyn gia thc

hin nhng nhm mc ch bo v cc nhm cng ng. V d, vn ng cm qung co thuc l, buc i m bo him khi i xe my trn ng cao tc...
3. T vn: Nhng can thip ny do khch hng nm vai tr chnh ch trng n

pht trin c nhn. Ngi lm cng tc sc khe c chc nng l mt ngi hng dn hn l mt chuyn gia. V d mt cn b tr lm vic vi cc on vin thanh nin gip h xc nh c cc nhu cu v sc khe v sau cng h to nim tin v hnh thnh cc k nng cn thit t mc tiu NCSK.
4. Pht trin cng ng: Tng t nh t vn, nhng can thip ny nhm gip

to iu kin hon thin cc k nng ca mt nhm ngi hoc mt cng ng. V d ngi lm cng tc cng ng lm vic vi mt s h gia nh nhm tng cng nhiu hn na c hi hc tp v thc hin cc hnh vi n ung hp v sinh. Mi chin lc nu trn da trn cc quan im khc nhau. Quan im bo th nhn nhn vic NCSK l cc hot ng nhm hon thin hoc sa cha nhng g c cho l sai st. Cn theo quan im ci cch th NCSK l cc hot ng nhm hon thin hoc sa cha nhng g c coi l xung cp. Nhng quan im ny to nn cc cch tip cn mang tnh p t da trn nhng quy tc nht nh. C hai trng phi u nhn nhn NCSK l nhng hot ng to iu kin hoc trao quyn lm ch cho cc c nhn. Ngoi ra, quan im c bn ny cn nhm mc ch huy ng v gii phng cc cng ng. M hnh ca Beattie rt hu ch i vi nhng ngi lm cng tc NCSK. N gip xc nh c s r rng quyt nh mt chin lc v nhc nh h rng vic la chn cc can thip lun b nh hng bi cc mi trng chnh tr v x hi.

56

Kiu can thip C tnh chuyn quyn/p t Kiu t duy Kin thc khch quan

Thuyt phc nng cao sc khe: - Thuyt phc v khuyn khch ngi dn chp nhn cc hnh vi mi c li cho sc khe. - Thy thuc ng vai tr chuyn gia/ ra lnh - T duy chnh tr bo th - Cung cp thng tin v a ra li khuyn Trng tm C nhn

Hnh ng mang tnh lut php: - Bo v cng ng bng cch m bo s sn c ca cc dch v c li cho sc kho - Thy thuc ng vai tr ngi bo mu, h bit rng iu g gip NCSK ngi dn - T duy chnh tr ca cc nh ci cch - Xy dng chnh sch v vn ng hnh lang can thip Tp th

T vn: Trao quyn lm ch cho cc c nhn gip h c k nng v t tin kim sot sc kho ca mnh Thy thuc ng vai tr t vn T duy mang tnh nhn vn T vn v gio dc

Pht trin cng ng: H tr cc nhm qun th hoc cng ng gip h thy h c g chung v nhng yu t x hi tc ng nh th no ln cuc sng ca h Thy thuc ng vai tr vn ng v h tr Xy dng chnh sch v vn ng hnh lang

Kiu can thip Thng lng Kiu t duy C s tham gia, Kin thc ch quan

S 3.2: S dng m hnh Beattie phn tch hnh ng

(Naidoo J., 2000 , Health Promotion)

57

2.2. M hnh ca Tanahill (1996)

M hnh NCSK ny kh ph bin v c p dng rng ri. Tannahill a ra ba phm vi hot ng c phn lng ghp vi nhau l: gio dc sc khe, bo v sc khe v phng bnh (S 3.3). Gio dc sc khe truyn thng, gio dc sc kho nng cao hiu bit v sc khe v phng bnh, thay i thi v thc hin hnh vi lnh mnh. Phng nga - gim hoc trnh nguy c mc bnh v au m thng qua cc can thip y t. Bo v sc khe - bo v sc khe nhn dn bng cc bin php x hi, ti chnh v lp php.

Gio dc sc kho
2 1 4 7 6

Phng bnh

Bo v sc kho

S 3.3: M hnh nng cao sc khe ca Tannahill.

Trong 1. Cc dch v d phng nh tim phng, khm sng lc ung th c t cung, pht hin ca bnh tng huyt p... 2. Gio dc sc khe: cung cp thng tin v hng dn b ht thuc l. 3. Liu php d phng: b sung fluor vo nc nga su rng. 4. Gio dc sc khe nhm ci thin sc khe v phng nga nguy c i vi sc khe nh vn ng hnh lang ban hnh lut buc s dng m bo him khi i xe my. 5. Gio dc sc khe tch cc nh bi dng k nng sng cho thanh thiu nin. 6. Bo v sc khe tch cc nh ban hnh chnh sch cm ht thuc ni lm vic. 7. Gio dc sc khe nhm bo v sc khe tch cc nh vn ng hnh lang cm qung co thuc l.

58

S Tannahill a ra cho thy cc bin php khc nhau c lin quan cht ch vi nhau trong mt qu trnh tng hp, c gi l NCSK. M hnh ny ch yu nhm m t nhng g ang din ra trong thc t. N gip cho nhng ngi lm cng tc NCSK nhn thy c li ch tim nng t hot ng khc v nm c ni dung ca NCSK. Tuy nhin, iu ny khng gii thch r rng ti sao ngi thy thuc c th chn bin php ny m khng chn bin php khc. M hnh ny cho rng cc bin php c tng tc ln nhau, v nh chng ta thy, chng phn nh cc cch tip cn khc nhau khi nghin cu cc vn sc khe.
2.4. M hnh ca Tones (1994)

M hnh ny hot ng da trn nguyn tc chnh l gip con ngi kim sot c sc khe ca chnh mnh. N ch trng ch yu n vic to iu kin cho i tng c kh nng nhn thc v hnh ng theo mc tiu ra. y cng l mc tiu v chin lc ct li ca m hnh ny nhm h tr v quyt nh cc can thip NCSK. Tones a ra mt phng trnh n gin cho rng vic tng cng sc khe l mt qu trnh tng th ca chnh sch cng lnh mnh nhn vi GDSK (S 3.4). ng coi gio dc l yu t ch o to iu kin cho c nhng ngi c chuyn mn hay khng c chuyn mn bng cch nng cao nhn thc ca h v cc vn sc khe. Khi con ngi c nhiu kh nng la chn v to p lc i hi vic ban hnh cc chnh sch cng c li cho sc khe. Chng ta thy c mt s khc bit gia vic to iu kin cho bn thn v to iu kin cho cng ng. Tones cho rng c mi tng tc ln nhau gia hai qu trnh ny.

Chnh sch cng lnh mnh p lc ca cng chng

Vn ng ng h

Mi trng t nhin v x hi lnh mnh

iu nh Cc t chc NCSK

S tham gia ca cng ng

Sc kho Dch v y t

Nng cao nhn thc Thit lp chng trnh ngh s

La chn sc khe Trao quyn

o to chuyn mn

Gio dc sc khe

S 3.4. M hnh nng cao sc khe ca Tones

59

Nhng thay i v mi trng x hi t c thng qua cc chnh sch cng c li cho sc khe s to iu kin thun li cho s pht trin ca cc c nhn. Nhng ngi c k nng tham gia c hiu qu vo vic a ra quyt nh c kh nng tip cn cc ngun thng tin v hnh thnh chnh sch tt hn p ng nhu cu ca mnh. S h tr ca cc c nhn cng cn thit cho qu trnh thay i. Ngc li vi bin php d phng, bin php trao quyn /tng cng kh nng lm ch v sc khe l mc ch chnh ca NCSK trong m hnh ca Tones. Tin hnh bin php trao quyn nhm nng cao tnh t ch v to iu kin cho cc c nhn, cc nhm v cng ng kim sot cuc sng ca h nhiu hn na. Tm li, bi ny xem xt nm cch tip cn khc nhau trong NCSK, chng bao gm: bin php y t; bin php thay i hnh vi hoc li sng; bin php gio dc sc khe; bin php trao quyn lm ch v sc khe v pht trin cng ng; v bin php vn ng to ra mi trng thun li cho sc khe. Thc t, ranh gii gia nhng bin php ny i khi khng r rng. Tuy nhin, nhng bin php ny v bn cht l khc nhau. Chng da trn cc gi thit khc nhau c lin quan n bn cht ca qu trnh thay i nhm NCSK. Cc phng php can thip thch hp, cc k nng cn thit v cc phng tin nh gi u khc nhau. Thng thng cc bin php NCSK cng nh cc cch tip cn v m hnh s dng thng b chi phi bi cc chc nng v m t cng vic ca chnh nhng ngi lm cng tc ny. Bi ny nhn mnh vo tm quan trng ca vic xem xt cc cch tip cn khc nhau v xc nh nhng thay i m ngi lm NCSK mun t c.
cu hi tho lun

Hy la chn mt vn sc khe ti a phng, phn tch v xut cch tip cn hoc p dng m hnh NCSK lp k hoch ci thin tnh trng ny. Ti sao bn li chn (cc) cch tip cn/phng php hoc m hnh ny?
TI LIU THAM KHO
1. Wiley (1993). Social and Behavioral Change Strategy. Health Education

Quarterly, Sup 1, p:113-135

2. Naidoo and Wills (2000) Health Promotion: Foundation for Practice. Royal

College of Nursing, p: 91-111

60

Phn 2

Nhng k nng chnh trong Nng cao sc kho

61

PHNG PHP TRUYN THNG SC KHO

MC TIU
1. Trnh by c khi nim truyn thng v qu trnh truyn thng. 2. Trnh by c cc hnh thc truyn thng. 3. M t c cc phng tin truyn thng i chng (TTC). 4. Trnh by c cc phng thc tip cn truyn thng. 5. Trnh by c cc phng php v k nng gio dc sc khe. 1. QU TRNH TRUYN THNG 1.1. Khi nim truyn thng

Truyn thng l qu trnh trao i thng tin nh nhng tng, cm xc, kin thc v k nng gia con ngi vi nhau. Truyn thng c th l nhng cuc i thoi bnh thng nh gii thch mt ch , mt ni dung no ; hi mt cu hi hoc ch l cuc tr chuyn hng ngy. Trong GDSK v NCSK, chng ta giao tip, i thoi, truyn thng nhm mc ch nng cao hiu bit, thay i thi v hnh vi theo chiu hng tch cc, gp phn ci thin tnh trng sc khe. phm vi rng hn, truyn thng tc ng n con ngi to ra s thay i nhng yu t con ngi, x hi v chnh tr nh hng n hnh vi sc khe v vic ra quyt nh lin quan n NCSK. t c mc ch ny, qu trnh truyn thng phi tri qua nhiu giai on v mi giai on phi t c nhng hiu qu nht nh (S 4.1). Ngi pht tin Ngi nhn tin

Cc gic quan nhn c thng tin C s ch Hiu c thng ip Chp nhn/Thay i Thay i hnh vi Ci thin sc khe
S 4.1: Cc giai on truyn thng

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Giai on 1: Thng tin n vi i tng Truyn thng khng th c hiu qu tr khi i tng nhn thy nghe thy nhng thng ip. iu ny thc s rt r rng v khng cn bt k l thuyt no gii thch. Tuy nhin c nhiu chng trnh khng c hiu qu ngay ti giai on c xem l n gin ny. Nguyn nhn tht bi thng gp l cch truyn ti thng ip khng ph hp. V d: t nhng bng tin khu khm bnh hoc nhng bui ni chuyn ti phng chm sc trc sinh. Nhng thng ip ny ch chuyn n mt s lng i tng t i n dch v. Nhng trong khi nhng i tng cn nhn c thng tin c th khng n khu khm bnh nhng h thng nghe i hoc c bo. H c th bn vic vo thi im chng trnh GDSK pht tin. Nhng chng trnh truyn thng nn thc hin ti nhng a im, v tr m i tng c th nghe tin, xem tin tc. Ngi lm truyn thng cn nghin cu i tng d kin tm hiu v tr i tng c th xem bng tin, h thng nghe nhng g v thi quen c ca h th no. Giai on 2: Thu ht s ch ca i tng Bt k qu trnh truyn thng no cng cn phi thu ht s ch lm cho i tng c gng c hoc nghe nhng thng tin ca chng trnh. Nhng v d v truyn thng khng hiu qu trong giai on ny nh: i qua mt bng tin m khng h nhn vo bng tin; khng h ch n ni chuyn v sc khe hay nhng bui hng dn ti cc c s y t; trng by, trin lm lin quan n sc khe nhng rt t ngi dng li xem; hoc tt i hoc chuyn knh khi nghe bn tin. Ti mt thi im chng ta c th tip nhn nhiu thng tin bi nhiu gic quan, tuy nhin kh c th tp trung tt c cc gic quan thu nhn thng tin trong cng mt thi im. Con ngi c th ch tp trung vo mt ch m c th b qua nhng ch khc. C nhiu cch lm cho qu trnh truyn thng hp dn i tng m chng ta s bn thm trong nhng phn sau. Giai on 3: Lnh hi thng ip Khi mt c nhn ch n mt thng ip ngi ta s c gng nhn thc, lnh hi thng ip. Lnh hi l mt qu trnh c tnh c nhn rt cao; hai ngi cng nghe mt chng trnh pht trn i, hay cng xem mt bng tin qung co, tuy nhin cch hiu v din gii ngha c th khc nhau so vi ngha ngi pht tin mun ni. S din gii ca c nhn v thng ip truyn thng ph thuc nhiu yu t. S hiu nhm c th d dng din ra khi: ngn ng s dng phc tp, s dng nhiu thut ng k thut/chuyn mn khng quen thuc; nhiu s /biu phc tp; c nhiu chi tit phn tn s ch ; nu ra nhng ch khng quen thuc...; mt l do khc gy hiu nhm l thng tin qu nhiu. Giai on 4: Thc y chp nhn/thay i Thng ip truyn thng khng ch c tip nhn v hiu m n cn nn to ra nim tin v s chp nhn i tng. Nim tin v mt ch kh thay i nu hnh thnh t lu v d dng thay i hn nu n mi hnh thnh. Thng thng cng d dng hn thc y hnh thnh nim tin nu nhng tc ng ca n d dng biu hin r, v d ci thin h thng thng hi ca h x s lm gim i mi hi thi, iu 63

ny s lm cho ngi dn nng thn tin tng v thay i h thng thng hi. Nu nim tin tn ti rng ri trong cng chng hoc tr thnh nim tin c tnh h thng nh mt tn gio th chng ta c th d on trc l khng d dng thay i hnh vi bng truyn thng i chng. Phn sau s cp chi tit hn xem ngun tin v ni dung c nh hng n nim tin v s chp nhn ca i tng nh th no? Giai on 5: Thay i hnh vi Qu trnh truyn thng c th lm cho nim tin v thi ca i tng thay i nhng hnh vi vn khng thay i. iu ny c th xy ra khi truyn thng khng nhm vo nim tin c nh hng nhiu n thi hng n hnh vi ca c nhn. V d nhiu chng trnh truyn thng qu nhn mnh n s nguy him ca bnh tiu chy m khng nhn mnh n vic phng mt nc bng cch b nc v cc cht in gii. Mt ngi c th c thi tch cc v mun hnh ng nh b m mun s dng bin php nga thai hay a con i tim chng. Tuy nhin, p lc t pha nhng ngi khc trong gia nh hay cng ng c th lm cho h khng th thc hin mong mun ca h. Mt l do khc lm cho c nhn khng thc hin hnh vi mong i l thiu nhng yu t to iu kin thun li cho s thay i nh: ti chnh, k nng, thi gian hoc yu t dch v y t. Vai tr ca cc yu t vn ha, nim tin, p lc x hi v cc yu t to iu kin thun li c cp chi tit trong bi trc. Giai on 6: Ci thin tnh trng sc khe Nhng ci thin, thay i v sc khe s din ra nu nhng hnh vi nh hng n sc khe thay i theo chiu hng tch cc.
1.2. Cc thnh phn ca qu trnh truyn thng

Qu trnh truyn thng l mt qu trnh khp kn bao gm hai hot ng c bn, hot ng chuyn thng ip t ch th pht tin ti ch th nhn tin, v hot ng phn hi t ch th nhn tin ti ch th pht tin. Cc thnh phn ca qu trnh truyn thng c m t nh s 4.
Nhiu: mi trng t nhin, tm l

THNG IP
Ch th pht tin Knh truyn thng Ch th nhn tin

Phn hi

S 4.2. M hnh qu trnh truyn thng

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1.2.1. Ch th pht tin

y chnh l ngun pht tin. Ngun pht c th l mt c nhn, mt nhm, mt c quan, t chc. V d: nhn vin y t, Hi ch thp , Trung tm y t... Ngi dn tip xc vi nhiu ngun tin khc nhau v h c kh nng tin nhng g n t nhng ngi hoc nhng c quan/t chc m h tin tng, l nhng ngun tin ng tin cy. Ty thuc tng cng ng, s tin cy v ngun tin ng tin cy c th l: mt ngi ng u cng ng; nhng ngi c chuyn mn cao, c o to bi bn; c cn nhc n yu t tui, gii, vn ha, hc vn ca i tng.
1.2.2. Ch th nhn tin

L i tng nhn cc thng ip. H c th l mt c nhn, mt nhm hay ton th cng ng. V d: mt x, huyn; nhm i tng nghin chch ma tu, nhm ngi bn mu chuyn nghip... Trong hot ng truyn thng, vic xc nh cc i tng truyn thng ch trong cc chin dch thng tin, gio dc, truyn thng l ht sc quan trng. l c s chng ta xy dng c cc thng ip v cc ti liu h tr mt cch c ch v thch hp vi i tng. Cn phi m t chi tit cc c im v kin thc, s thch, nhu cu, mi quan tm, cc knh truyn thng thng tip cn v cc u tin ca cc nhm i tng truyn thng ch. Vic c gng tip cn vi tt c cc i tng bng cng mt thng ip truyn thng hoc chin lc truyn thng c th lm cho cc thng ip tr nn km hiu qu v chng c th khng thu ht c s ch ca cc nhm i tng truyn thng ch. Vi mi nhm i tng, cn tm hiu v cc c im th cht, nhn khu hc v c th c cc c im tm l. Trn c s ny, ta s la chn c cc chin lc tip cn v qun l tt hn vi tng nhm trong cng ng. Vic phn nhm i tng ch c th da trn cc c im sau y: Theo c im th cht gm: gii tnh, bnh s gia nh, cc dng v mc phi nhim vi cc nguy c sc kho, cc iu kin v mt y t, cc biu hin v bnh tt. Theo c im hnh vi gm: hnh vi c lin quan, tc ng n sc khe v cc c im khc v li sng. Theo c im nhn khu hc gm: ngh nghip, thu nhp, trnh hc vn, hon cnh gia nh, ni lm vic v ni , cc c im v vn ho. Theo c im tm l gm: thi , tng, nim tin, chun mc, gi tr x hi, s t nh gi bn thn v cc c tnh c nhn khc. Hiu bit v nhm i tng ch cng chi tit, y bao nhiu th s cng d dng by nhiu trong vic chun b mt chng trnh truyn thng thch hp vi i tng. Trong thc t vic phn nhm thng phi hp cc c im ca cc cch phn loi ny. 65

C th phn nhm i tng truyn thng theo mc u tin nh i tng ch cp I v i tng ch cp II. i tng ch cp I l nhng ngi m chng ta mun tc ng n thay i hnh vi ca chnh h. Thng thng, c nhiu nhm i tng ch cp I trong khi cc ngun lc li c hn, nn chng ta cn phi la chn nhm i tng u tin tin hnh cc hot ng truyn thng. La chn u tin s gip chng ta c th lp k hoch v phn b cc ngun lc mt cch thch hp thc hin chng trnh truyn thng cho tng nhm i tng. Nhm i tng truyn thng ch cp II l nhng ngi c nh hng n nhm i tng ch cp I hoc l ngi c th tc ng to ra s thay i nhm i tng ch cp I. V d: nhm ph huynh, nhm bn thn, ng nghip, thy c gio... Vic xc nh r cc nhm i tng ch s gip chng ta c hng i ng trong vic pht trin v ph bin cc thng ip truyn thng v s dng hiu qu cc ngun lc ca chng trnh.
1.2.3. Thng ip truyn thng

L nhng thng tin chnh c m ho di dng ch vit, tranh nh, k hiu hoc biu tng cn chuyn n i tng, gip i tng tng kin thc, tc ng n thi , nim tin nhm thay i thi v hnh vi sc kho theo chiu hng c li. Thng ip l nhng ni dung chnh, ch yu trnh by ngn gn v thuyt phc v mt ch , vn sc kho. Ni dung ca thng ip phi phn nh c mc tiu truyn thng. V d nu mc tiu c bn l to ra mt quyt nh hnh ng t pha i tng, th thng ip phi cha ng nhng hnh ng c th m i tng s thc hin. Thng ip cn phi ngn gn, r rng v c tnh thuyt phc. Nn s dng cc s liu thc t, cp nht to thm sc mnh cho thng ip. Nhng thng ip tt thng kt hp cht ch cc t ng, cc mnh hoc tng hoc tranh nh minh ha mang tnh tch cc, c ngha i vi i tng ch. Cn ch nm yu t c bn sau y khi xy dng v chuyn ti thng ip: Ni dung: Th hin r nhng tng cn truyn t. Nhng lp lun c s dng thuyt phc i tng. Ni dung thng ip thng bao gm: iu bn mun t c, ti sao mun t c iu , bng cch no t c iu v hnh ng g bn mun i tng thc hin. Mt iu cng rt quan trng l phong cch ca thng ip tc ng n i tng, v d nh: thng ip c tnh gy s hi, c tnh e da; gy ra cm gic lo ngi; c tnh nghim tc; c tnh hi hc; to ra xc cm; to ra p lc; c tnh nhc nh trch nhim; c tnh khch l thc hin... Tu thuc vo cc c trng ca i tng, tu ch GDSK m cn thit k thng ip c ni dung cho ph hp v hiu qu. Ngn ng: S dng t ng th no thng ip c truyn t r rng v hiu qu l ht sc cn thit. Nhng thng ip tt thng kt hp cht ch cc t, cm t hoc cc khi nim c ngha khi qut, tch cc hoc c ngha c bit i vi cc i tng cn vn ng. Nn dng ngn ng quen 66

thuc vi nhm i tng ch, trnh dng nhng thut ng chuyn mn nu tht s khng cn thit. Nu cn phi s dng bng, s , th th chng phi n gin, d hiu v c ch thch y , r rng. Ngun tin v ngi a tin: Hy s dng thng tin t nhng ngun d liu ng tin cy. Hy la chn nhng ngi lm cng tc truyn thng, GDSK, ngi chuyn tin c th to ra cm gic tin cy v nhng phn ng tch cc t pha i tng. Ngi a tin i khi quan trng hn c thng ip. V d: nu chng trnh ang c gng tc ng n cng chng thng qua bo ch, th nn s dng nhng loi bo hng ngy c ng o ngi c v c uy tn. Nu chng trnh ang hng mc tiu vo nam gii, hy th tc ng n h thng qua cc t chc Cng on, on thanh nin, Hi Cu chin binh, Hi nng dn, Cu lc b... Hnh thc chuyn ti thng ip: Hy la chn cch truyn thng ph hp nht. Chng hn, chuyn thng ip qua cc cuc hp, cc din n; hoc gi thng ip qua th; hoc pht thng ip qua cc chng trnh truyn hnh, bo ch. Cn ch rng cc thng ip s khng thu ht ngay c s ch , cng nh tc ng ngay n quan im ca i tng, v vy qu trnh truyn thng lp i lp li v trn nhiu knh l rt quan trng. Tnh nht qun ca ni dung thng ip nn c duy tr cho n khi n thu ht v c tc ng n i tng ch. Thi gian v a im chuyn ti thng ip: L yu t cn ch c c mt thi im tt nht ti a im thun li nht cho vic chuyn ti thng ip v c nhiu i tng tip cn thng tin nht. Thit k, chun b ti liu l vic ht sc quan trng. La chn thng tin ph hp, trnh by chng theo nhng cch khc nhau, cho nhng i tng khc nhau to s cun ht v hp dn nht cho tng nhm i tng. i vi truyn thng i chng, thng tin c th c trnh by di hnh thc thng co bo ch, s dng ngn ng v vn phong thng dng trong bo vit hoc bo hnh. Nhng thng tin nu dnh cho nhng ngi ra quyt nh, ngi hoch nh chnh sch c th trnh by di dng bn tin gm nhng thng tin c tnh bng chng khoa hc, nhng lp lun khoa hc, nhng bng d liu thng k, nhng s , th... Cn chn nhng thng tin t kt qu ca qu trnh nh gi ban u, nu n c th cung cp nhng lp lun c tnh thuyt phc nht i vi tng i tng ch. Cch trnh by thng ip quan trng khng km v n gp phn hp dn i tng. Loi sn phm cha ng thng tin c th l cc ti liu in, cc sn phm nghe, hoc nghe - nhn. Nn cung cp thng tin ti thiu c th t c mc tiu, sau c th cung cp thng tin thm, nhiu hn. Minh ha bng tranh nh, th, biu cng l nhng hnh thc cung cp rt nhiu thng tin trong mt khng gian hn ch v nhiu khi tc ng ca n ln hn li ni v ch vit rt nhiu, ng thi chng cng gip minh ho nhng thng tin ct li trong thng ip. C knh truyn thng v mc tiu ca truyn thng sc kho u c nh hng n vic thit k ni dung truyn thng nhm ti a hiu qu ca qu trnh truyn thng. V d vng su vng xa, ni tip cn phng tin i chng hn ch th thng 67

ip c chuyn qua knh trc tip l ch yu; ni c tip cn cc knh i chng d dng th thng ip s c thit k thch hp vi cc phng tin truyn thng i chng. Mt s yu t nh hng n s chp nhn cc thng ip truyn thng ca cng chng bao gm: S r rng: Cc thng ip truyn thng phi r rng v d hiu, hn ch ti a vic hiu sai v ni dung hoc c nhng hnh ng khng thch hp. Cc thng ip truyn thng cha ng cng t cc thut ng k thut cng tt, ng thi gim bt cc thng tin khng lin quan n i tng truyn thng ch. S thch hp v mt vn ho: Ni dung truyn thng phi thch hp vi nim tin, gi tr x hi v vn ho ca i tng truyn thng. tin cy: Ngi truyn tin v cc ngun thng tin phi ng tin cy. Cc im chnh: Cc im chnh trong ni dung truyn thng cn c nhn mnh v lp li. Hnh thi truyn thng: Mt thng ip truyn thng c th c nhc i nhc li, gy s hi, a ra thch thc, hoc i thng vo vn cn truyn thng. Vic la chn hnh thi truyn thng ph thuc vo mc nh hng m chng trnh mun tc ng ln i tng ch. p ng nhu cu ca i tng: Ni dung truyn thng cn phi da trn s nhn thc ca i tng truyn thng, nhng g l quan trng i vi h, nhng g h mun bit, hoc khng cn bit. Li ch ca i tng truyn thng c hiu l h s t c ci g m h nhn thc l quan trng v c ngha i vi h v c th khc nhau i vi mi nhm i tng. Mt s yu t khc c th lm tng hiu qu ca thng ip truyn thng nn cn nhc thm khi thit k thng ip gm: Tnh i thng - ni dung thng ip gn gi vi cuc sng to cm xc tch cc, gy n tng i vi i tng, gip i tng d nh, d thc hin. Mt cu chuyn n gin c th rt d nh; cu chuyn ny c th chuyn ti vn sc kho cn tuyn truyn v gii php cho vn . Tnh hi hc - c th gy n tng v lm cho i tng nh thng ip, nhng rt kh lm tt. i vi mt vi nhm i tng hoc mt vi ch nhy cm, s hi hc c th dn n b cng kch. To cm xc - c th lm cho cc thng ip tr nn hin thc, ring t v to ra nhng cm xc tch cc, c th gip cho i tng chuyn i hnh vi ca mnh theo mc ch ca thng ip. Nhng cch ny c th gy ra s lo lng, s hi, chnh v th cn phi tht cn trng khi vn dng. Dng m nhc - m nhc gip thng ip tr nn d tip thu hn, n c th khi gi tnh cm ca ngi nghe i vi thng ip. Cn ch khi s dng m nhc v n c th lm phn tn s ch v lm cho thng ip b lu m. 68

Khi xy dng cc thng ip v sc kho cn phi xem xt, cn nhc cc yu t trn. Trc khi a ra bn tho cui cng, cc thng ip cn phi c th nghim trc trn nhm i tng truyn thng ch m bo tnh tip cn v chp nhn ca i tng.
1.2.4. Knh truyn thng

L phng tin, l cch thc chuyn thng ip n i tng. C th phn ra hai loi knh truyn thng chnh: Knh truyn thng trc tip: ni chuyn mt i mt, t vn, tho lun nhm, hi hp, tho lun... Knh truyn thng i chng (gin tip): giao tip, truyn thng thng qua nhng phng tin truyn thng i chng (truyn thanh; truyn hnh, cc ti liu in n: bo, tp ch, t ri, s nh...; tranh qung co, bng tin ln...). Quyt nh s dng knh truyn thng no ph thuc vo tng vn sc khe, mc tiu v chin lc c th. Cc th loi ti liu truyn thng cng gip ta la chn knh hp l. Nhng hnh thc truyn thng thng c s dng l: Ni chuyn, t vn trc tip thng qua tnh nguyn vin cng ng, ng ng, thnh vin gia nh. Truyn thng nhm qua cc cuc hi hp, tho lun ti cng ng, ti cng s, trng hc. Truyn thng i chng qua i truyn thanh, truyn hnh, tp ch, bo, t ri, bng tin, p phch, loa cng cng, bng rn. T chc cc loi hnh sn khu ha: ca ma nhc, kch, cc cuc thi vui v cc ch sc khe. Mi knh truyn thng u c nhng u im v hn ch ca n, v vy phi cn nhc k cng trc khi la chn knh truyn thng (bng 4.1). Cng cn ch rng cc knh truyn thng cng i hi cc ti liu/thng ip khc nhau v c hnh thc v ni dung. Knh truyn thng i chng c th chuyn ti thng tin nhanh v ti c ng o qun chng nhng chng ta khng th hy vng nhiu vo vic cc thng tin i chng c th lm cho mi ngi thay i hnh vi ca mnh. Thng tin i chng nhn chung c th c xem nh ngun thng tin cng cng c bn nhng b hn ch bi thi gian, a im, cht lng thng tin v cc yu t khc, nn knh truyn thng ny kh c th gii thch mt cch y v kp thi cc thng tin phc tp. Thng tin i chng thng qu ch trng n cc thng tin mi hoc cc thng tin ch tc ng n mt s nhm i tng. Mi mt hnh thc truyn tin nh tp ch, cc bi bo, bi pht thanh trn i, cc bui phng vn, trao i trn truyn hnh, cc chuyn mc sc kho... u c nhng u im ring v mi hnh thc c th tip cn vi mt s nhm i tng khc nhau. C th quyt nh chn cc hnh thc truyn tin v knh truyn tin khc nhau, hoc phi hp chng, nhng cn lu mt iu l nn chn cc knh truyn thng tip cn c vi i tng ch nhiu nht. 69

Knh truyn thng trc tip gia cc c nhn a ra cc thng ip sc kho trong ng cnh quen thuc vi i tng truyn thng hn. Hnh thc t vn sc kho cng l mt hnh thc truyn thng trc tip ph bin. Cc knh ny thng c tin cy v nh hng cao (ngi lm cng tc truyn thng l cc bc s, cc cn b y t cng ng, bn b, cc thnh vin trong gia nh, y l cc ngun lc rt ng tin cy). Do c im l gy nh hng thng qua mi lin h c nhn, nn i hi ngi lm cng tc ny phi rt quen thuc vi ni dung truyn thng v t c th theo di mc tip cn v chp nhn lu di ca i tng. Knh truyn thng ny c chng minh l rt hiu qu trong nhiu chng trnh y t v chng trnh pht trin. Vit Nam, hin nay cc tnh nguyn vin, cc cng tc vin cng ng c vai tr quan trng v ang tin hnh tuyn truyn, GDSK c hiu qu ti cng ng. Cc knh truyn thng (bao gm trng hc, cng s v cc n v truyn thng) c th tng cng v m rng cc ni dung truyn thng v a ra nhng hng dn. Cc knh truyn thng mc gia cc c nhn v mc cng ng c th h tr ln nhau: Cc knh truyn thng cng ng cho php tin hnh tho lun vn v knh truyn thng c nhn lm r cc thng tin v khuyn khch s thay i hnh vi. Phi hp cc knh truyn thng khc nhau s tng cng tn sut xut hin ca ni dung truyn thng, tng cng cc c hi cho i tng ch tip thu v ghi nh thng tin. Cn xem xt cc cu hi di y khi tin hnh chn knh truyn thng: Knh truyn thng no l ph hp nht cho mt ni dung truyn thng v ch /vn sc kho cn truyn thng? Knh truyn thng no c uy tn v d tip cn vi i tng ch? Knh truyn thng no thch hp vi mc tiu ca chng trnh? Knh truyn thng no c kh nng thc thi trong gii hn thi gian v kinh ph ca chng trnh? u truyn thng c th gy c s ch v p ng c nhng n lc v tuyn truyn gio dc? Ni no chng ta c th tm c cc i tc tt nht? Bng 4.1. Nhng c im chnh ca knh truyn thng i chng v truyn thng trc tip
c im Tc bao ph thng tin cho s ng i tng chnh xc v t b nhiu Kh nng la chn i tng Chiu hng truyn thng Kh nng p ng nhng nhu cu a phng Phn hi Tc ng chnh Truyn thng i chng Nhanh chun xc cao Kh la chn i tng Mt chiu Ch cung cp thng tin chung Phn hi gin tip t nhng iu tra Nng cao hiu bit, kin thc Chm D b sai lch thng tin C tnh la chn cao Hai chiu C th p ng nhu cu a phng C th phn hi trc tip Nhng thay i v thi , hnh vi, k nng gii quyt vn . Mt i mt

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1.2.5. Phn hi

L nhng thng tin, kin t pha ch th nhn tin n ch th pht tin. Da vo phn hi m ch th pht tin nh gi c tc ng ca truyn thng n i tng, cng nh c nhng iu chnh thch hp v ni dung, thng ip, hnh thc, knh truyn thng...
1.2.6. Nhiu

L nhng yu t mi trng tc ng n qu trnh truyn thng. V d: ting n c th nh hng n s tip thu ni dung thng ip truyn thng...
2. PHNG TIN TRUYN THNG 2.1. Cc phng tin truyn thng i chng

Cc phng tin TTC c chia lm hai nhm: Cc phng tin truyn thng c kh nng tip cn mt s i tng nht nh. Cc phng tin truyn thng c kh nng tip cn rng ri cc nhm i tng.
2.1.1. Cc phng tin truyn thng i chng c kh nng tip cn mt s i tng nht nh

Sch mng Sch mng l ti liu thch hp nht cho mc ch cung cp kin thc v khi c nhng ngun h tr thng tin khc nh cc c s y t, cc trung tm gio dc truyn thng. Cn thn trng s dng sch mng trong trng hp mun thay i hnh vi c nhn, v bn thn thng tin thng khng dn ti vic thay i hnh vi. Sch mng nn c s dng kt hp vi nhng loi hnh truyn thng khc. T ri (t gp, t bm) Loi hnh ny cng rt ph bin v s dng thun tin. c s dng trong trng hp c gi khng c nhiu thi gian c. T ri l mt loi ti liu truyn thng quan trng trong cc chin dch TTC. Ni dung trong t ri thng rt ngn gn, c ng nhng thng tin cn thit nht nh "Nhng iu cn bit v nui con bng sa m", "Nhng iu cn bit v HIV/AIDS" v nhiu ch khc. Trong cc bui tho lun nhm, ni chuyn, thm h gia nh, t vn ngi gio dc sc khe c th pht t ri, sch nh hng dn v chm sc sc khe cho i tng. T ri, sch nh cn c trng by v i tng la chn, c, mang i ti nhng gc, phng gio dc sc khe ca cc c s y t, hoc ti cc trin lm v y t. Tranh lt hay sch lt y l mt lot cc bc tranh, nh trnh by v mt ch , mt vn sc khe no . Tranh lt c th trnh by mt cch trnh t, n gin v mt bnh ngi 71

hc, ngi xem c th hiu v vn dng. Thng s dng kt hp trong cc bui ni chuyn sc khe trc tip vi c nhn, vi nhm. Tp ch Tp ch cng l mt phng tin truyn thng c th s dng ng ti cc thng tin y t. Tp ch l mt phng tin c th ng ti nhng thng tin chuyn . Tuy nhin mi tp ch thng ch dnh cho mt s nhm c gi nht nh, do m kh nng tip cn thng b hn ch. Mt hn ch c bn hin nay l gi c ca tp ch thng qu cao so vi thu nhp ca i a s ngi dn. p phch /Pa n L nhng bng ln, t giy ln v cc bc tranh, biu tng v nhng cu ngn gn th hin mt thng ip truyn thng, gio dc sc khe no nh: nguyn nhn, triu chng, ng ly, hu qu, cch phng chng mt bnh... Loi hnh ny thng t, treo nhng ni cng cng nn gy c s ch ca nhiu ngi. L mt loi ti liu c s dng h tr cho cc ti liu khc trong cc chin dch truyn thng nh c ng nhn nhng s kin c bit. Vic thit k pa n, p phch i hi ngi c chuyn mn, k thut v cng tn km. Khi tin hnh sn xut pa n, p phch cn ch ch trnh by mt vn , mt tng trnh nhm ln v kh hiu. Cc vt dng hng ngy (o phng, o ma, m, cp sch, ti khoc, dy eo cha kha, t dn) L loi hnh truyn thng ang c s dng ngy cng rng ri hn trong hot ng qung co v tip th. Yu cu ca loi hnh ny l thng tin phi c chn lc rt k lng v ngn gn ti a, thng di dng mt cm t hoc mt hnh nh. Nhng vt dng ny c th c ti tr hon ton (pht khng) hoc c ti tr mt phn (bn gi r). Bng, i cassette L loi vt liu truyn thng c s dng ghi m ni dung truyn thng s dng vi my cassette pht tin hoc pht tin qua loa. Vt liu ny s dng ph bin trong cc chin dch TTC. Cn th nghim ging c v thi lng c tin cho ph hp trc khi pht tin. Video y l loi phng tin nghe nhn hin i, sinh ng, hp dn. S dng n ch ng hn truyn hnh trong cng tc TT-GDSK. Loi hnh ny c th s dng cho nhiu nhm i tng. Vic chun b kch bn, chng trnh thu bng, k thut thu i hi ngi c chuyn mn, k thut ng thi cng cn c kinh ph thch hp cho cc hot ng ny. S dng video phi hp vi cc phng php khc nh ni chuyn, tho lun nhm s em li kt qu tt hn trong gio dc sc khe. cng ng, bng video thng ch c s dng trong nhng chin dch truyn thng cc cm dn c. Ngoi vn kinh ph v k thut sn xut, hn ch ln nht ca hnh thc ny l cn phi c trang thit b i km v ngun in sn sng. 72

Bo in t, internet y l phng tin TTC hin i trn mng internet. Lng thng tin v cng ln, a dng, cp nht nhanh. Loi hnh ny rt thng dng khu vc th v i tng s dng thng l gii tr, gii tr thc...vi yu cu c bn l c kin thc v k nng s dung my tnh v internet. Kh nng tip cn s dng loi hnh ny vng nng thn v vng su - xa cn rt hn ch.
2.1.2. Cc phng tin truyn thng c kh nng tip cn rng ri cc i tng

V tuyn truyn hnh (Ti vi) Ti vi l mt phng tin TTC quan trng bc nht hin nay v kh nng bao ph thng tin rng ri v tnh hiu qu ca n. Theo iu tra gn y, Vit Nam hin nay t l tip cn ti vi vo khong 70% h gia nh. Ti vi thng c s dng nng cao nhn thc v mt vn , tc ng vo tnh cm v to dng mt hnh nh lin quan n mt sn phm hoc hnh vi. Loi hnh ny thng hp dn i tng v ngoi li ni cn c hnh nh sinh ng minh ha gy n tng v nh lu, gip i tng nng cao hiu bit, thay i thi , hnh vi theo chiu hng tch cc. Cc thng ip v sc khe c th c pht sng bng nhiu hnh thc khc nhau nh phim nhiu tp, kch, din n, i thoi, qung co, tr chi ... Vic thit k, pht sng mt chng trnh trn truyn hnh thng l cng vic c tnh chuyn nghip, cng phu, chi ph cao nn cn c k hoch, s kt hp cht ch gia y t v truyn hnh khi thc hin chng trnh. i pht thanh i pht thanh cng l mt phng tin quan trng trong truyn thng, GDSK. So vi ti vi, i pht thanh c nhng u im nh din bao ph rng hn cc vng su vng xa, chi ph r hn. Cc thng ip gio dc sc khe c th c truyn n i tng qua i pht thanh di nhiu hnh thc nh: bi ni chuyn, bn tin sc khe, hi p v phng bnh. Vic la chn thi im pht tin trn i /loa cng cn lu c c mt s lng ng o ngi nghe nht. i tng tip cn loi hnh ny l qung i qun chng. Bo in Nhn chung bo l mt phng tin truyn thng i chng ph bin, tip cn nhiu nhm i tng, rt ph hp cho cc hot ng cung cp thng tin cp nht, qung co. Cc bn tin sc khe, bi vit v sc khe, hng dn phng bnh, rn luyn nng cao sc khe d dng ng ti S dng hnh thc bo ch thng t hiu qu cao v s ng ngi dn c th tip cn, thng ip c th hin trn bo vi hnh thc a dng, i tng c thi gian c v suy ngh k lng, gi c cho loi hnh ny chp nhn c. Tuy nhin, kh nng tip cn s dng bo cc i tng, cc khu vc c khc nhau, thi quen s dng bo in cc vng nng thn, vng su xa hin nay cng cn rt hn ch, do cn cn nhc yu t v a l, dn s hc, kinh t, loi bo a tin.

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2.2. La chn phng tin truyn thng i chng

Pht trin kinh t x hi trong nhng nm gn y to c hi cho vic s dng rng ri cc phng tin TTC phc v cho cc hot ng TT-GDSK. Khi s dng cc phng tin TTC, nhng ngi lm cng tc TT-GDSK cn xem xt rt k lng v loi phng tin truyn thng, u nhc im ca tng phng tin, phng php truyn thng s s dng, nhm i tng ch, kh nng ti chnh... t c hiu qu cao nht. TTC thng thng ch l mt phn ca cc chin dch hoc chng trnh, v thng c kt hp vi cc phng php truyn thng trc tip khc. Nhn chung mi phng tin TTC u c nhng u im v hn ch ca n, phn di y s tm tt u im v hn ch ca mt s phng tin TTC chnh. Bng 7. u nhc im ca mt s phng tin truyn thng
Phng tin i pht thanh u im C th tip cn c nhng khn gi khng bit c bng ngn ng ca h i thu thanh tng i r v nhiu ngi c th mua c C th s dng pin, khng cn in ngun, nn ph hp vi nhng vng su, vng xa C th pht sng nhiu ln trong mt ngy Vic sn xut v pht chng trnh l tng i r Din ph sng thng l rng hn ti vi Ti vi L phng tin hu dng cho nhiu i tng, d xem, d hiu C th ch cho khn gi cch thc hin mt vic no (truyn t k nng bng trnh din) C th a nhng hot ng ng vai, do gip khn gi d hiu hn C th nhiu vng khng c ph sng nh vng su, vng xa Mt s i tng khng tin mua Chi ph sn xut v pht sng chng trnh thng l t L phng tin truyn thng mt chiu Ch tip cn c vi nhng ngi bit c Gi bo, tp ch l kh cao so vi ngi thu nhp thp Nu a tin khng chnh xc, rt kh sa li. Hn ch Khng ph hp truyn t k nng thc hin mt hot ng nh cch s dng bao cao su v khng th minh ha bng trnh din Khn gi khng c c hi hi nu h khng hiu. Tuy nhin c th khc phc nhc im ny bng cch cung cp cc a ch t vn cho vn Mt s ngi c th khng tip cn c i pht thanh

Ti liu in n

c gi c th c li nu h cha hiu Mt bi bo hoc mt cun sch, t ri c th c truyn tay cho nhiu ngi Nhiu ngi tin tng cc bi vit hn l cc tin a trn i pht thanh hoc ti vi c gi c th gi li cc bi vit, cc tin xem li khi cn

74

2.3. Th nghim cc thng ip truyn thng

Tt c cc ni dung v thng ip TT-GDSK cn c th nghim trn cc nhm i tng ch trc khi a chng vo cc ti liu chnh thc. Vic th nghim s gim thiu cc yu t lm gim hiu qu ca phng tin truyn thng. Sau y l mt s phng php th nghim hay c s dng.
2.3.1. Bn cu hi t in

Mc ch: Thu nhn cc thng tin phn hi t cc i tng truyn thng i vi cc bn tho. p dng: Vi cc ti liu in n v nghe nhn. S lng ngi tham gia: Ty theo yu cu hoc c th tnh ton c mu. Chun b: Bng danh sch ngi tham gia, cc bn tho hoc ti liu mu, bng cu hi. Cn c bit ch phn hng dn tr li, phn ny cn ghi r yu cu v cc ni dung cn gp m bo thu c v ng thng tin cn thit. u im: Chi ph r, v khng cn ghi tn nn i tng c th mnh dn gp , d tip cn i tng v nhanh chng c c kt qu. Nhc im: c th c nhng sai s khi t in phiu, cc gp c th khng r rng nhng khng kim tra li c, c th khng thch hp vi cc nhm i tng hn ch k nng vit. Cn th nghim bng cu hi k lng trc khi tin hnh. Khng nn s dng phng php ny nu c th thc hin bng nhng phng php khc.
2.3.2. Phng vn c nhn

Mc ch: Thm d thi , phn ng, nim tin, mong i ca cc c nhn v tho lun v cc vn . p dng: C th th nghim k cc thng ip, cc kh nng thc hin chng trnh hiu qu, tho lun v cc vn t nh hoc l cc bn tho phc tp. S ngi tham gia: C th tin hnh trn mt s ngi ca tng nhm i tng cho tng loi ti liu. Yu cu: Danh sch nhng ngi tham gia, cc cu hi nh hng phng vn, cn phi tp hun cho ngi phng vn, my, bng ghi m v la chn mt a im yn tnh. u im: Cc gp t phng vn su thng l chi tit, c th, c gi tr tham kho chnh sa v hon thin ti liu, c th th cc ti liu truyn thng c tnh to cm xc cao hoc mang tnh hi hc. Hoc th nghim cc ti liu phc tp hoc di, c th tip cn vi cc nhm i tng kh tip cn. Phng vn su cn c s dng vi cc i tng c trnh hc vn thp, k nng vit km. Nhc im: Kh tn km, mt nhiu thi gian thc hin v phn tch.

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2.3.3. Phng vn ti cc t im

Phng vn ti cc t im l cch tip cn cc i tng ch ti cc ni m h hay n nh: ni chiu phim, cu lc b, ch, ni ch khm bnh cc bnh vin hoc sn trng... ri ngh h tham gia phng vn. Mt phng vn ti cc t im c bt u bng cch tip cn i tng, trnh by mc ch, nu i tng ng th tip tc hi h mt s cu hi phn loi c th xem h c ph hp vi cc tiu chun phn loi l i tng ch hay khng. Nu tho mn s tin hnh phng vn ti a im chun b hoc ni yn tnh quen thuc vi h. Cc bng hi c s dng trong kiu phng vn ny gm cu hi nhiu la chn hoc nhng cu hi ng cho php c phn hi nhanh. Mc ch: thu c nhng thng tin nh lng v ti liu v ni dung truyn thng. p dng: phm vi rng bao gm cc khi nim, cc n phm hoc cc ti liu nghe nhn. S lng ngi tham gia: ty theo yu cu c th m s lng i tng tham gia c tnh i din hay khng. Yu cu: bng hi c cu trc; cc iu tra vin phi c tp hun/tip cn i tng ti cc trung tm thng mi, trng hc, cc a im khc, phng phng vn; cc phng tin ghi m; cc sn phm nghe nhn. u im: c th thu c nhiu kin ng gp; kt qu phn tch s c gi tr hn cho vic ra quyt nh; c th th nghim nhiu loi ti liu. Nhc im: thng phi phng vn ngn, nhanh; cn thit phi khuyn khch /thuyt phc nhiu ln; khng th kho st k lng; kh thu thp thng tin i vi cc ch nhy cm; vic chn mu rt cht ch i vi cc i tng, ni phng vn; i tng c phng vn c th khng i din.
2.3.4. Tho lun nhm trng tm

Tho lun nhm trng tm c s dng c s hiu bit su sc v nim tin, thi , s chp nhn v ngn ng ca i tng. S lng i tng khong 8 - 10 ngi /nhm vi cc c im chung (v d: b m c con di 5 tui, nhm v thnh nin...). Cu hi hng dn tho lun cho php gi cuc tho lun i ng hng. Tho lun nhm trng tm c bit c li trong giai on pht trin cc tng, nim cho vic xy dng thng ip truyn thng. hng ta c th hiu bit su v nim tin, thi ca i tng truyn thng v cc vn sc kho. S thoi mi trong tho lun s cung cp cc gi gi tr cho pht trin cc ti liu theo ngn ng m i tng s dng v gi m nhng thay i theo nhng hng mi. Tho lun nhm s c ghi bng, g bng ri phn tch v a ra cc kt lun. Cc yu cu: Chng trnh tho lun; tp hun cho ngi hng dn tho lun, danh sch ngi tham gia; a im tho lun; phng tin ghi m; ghi hnh. 76

u im: Tng tc trong nhm v thi gian ca cuc tho lun cho php khai thc nhiu thng tin cn thit, tm ra c cc nim, ni dung chnh pht trin cc ti liu; c th thu c nhiu kin mt lc; c th tin hnh phn tch nhanh. Nhc im: Kh tn km; cc i tng c chn tham gia c th khng i din cho i tng truyn thng ch.
2.3.5. Cc test th kh nng c

Th nghim c ny ch n gin l on bit trnh hc vn phi c ca cc i tng truyn thng c th hiu c cc ti liu in n trong chng trnh. Cc ti liu v thng tin sc kho nh: sch, t ri, p phch, tp ch c thit k cho cc nhm i tng truyn thng ch ring bit; th nghim c c th ch ra mc thng tin m hu ht cc i tng truyn thng c th hiu c. Mc d t l bit ch ca Vit Nam cao, vn cn phi c cc th nghim c ny cc vng nng thn, vng su -xa m bo rng i tng truyn thng c th hiu c cc thng tin trong cc ti liu. Nh trnh by trn y, c nhiu loi ti liu truyn thng khc nhau, mi loi ti liu c th cn c nhng lu ring khi tin hnh th nghim. Tuy nhin tt c cc loi ti liu u c nhng im chung khi tin hnh th nghim, l mc ch v cc cu hi chnh cn tr li khi th nghim. Phn tip theo s a ra mt s gi thc hnh v th nghim ti liu truyn thng.
2.3.6. Hng dn thc hnh th nghim ti liu /thng ip truyn thng

Mc ch ca th nghim ti liu truyn thng: nh gi tnh d c, d hiu; nh gi kh nng nh li thng ip sau khi c/nghe/xem; Tm ra nhng im mnh v hn ch ca thng ip; Xc nh xem li ch c nhn thu c nu thc hin li khuyn nh thng ip c mnh thay i hnh vi hay khng; Tm kim nhng im nhy cm hoc gy tranh ci trong thng ip. Nhng ni dung chnh cn th nghim: Tn ti liu, hnh thc v cch trnh by, tnh hp dn, kiu v c ch, hnh nh minh ha; Kh nng lnh hi thng tin, lin h vi c nhn, tnh thuyt phc, kh nng chp nhn. Nhng cu hi chnh cn tr li khi th nghim: C nhn xt g/mc chp nhn nh th no vi hnh thc v cch trnh by ca ti liu/thng ip? (gm kch thc, mu sc, cc hnh nh minh ha). Hiu ti liu/thng ip/minh ha nh th no? C hiu ng khng? Ch no cha hiu v l do? 77

 Nhng hnh nh, thng tin trong ti liu c lin quan n i tng/bn/ngi thn ca i tng? Nu c th lin quan nh th no? C tin vo ti liu/thng ip khng? Mc nh th no? Ti liu/thng ip c tnh thuyt phc khng? Nh th no? Cn sa/thay i g tng tnh thuyt phc? Mc chp nhn ca i tng i vi ti liu/thng ip nh th no? Cn thay i nhng g? (gm c ngn ng, kha cnh vn ho, tn ngng). Chnh sa ti liu sau th nghim: Sau khi th nghim, chng ta thu c rt nhiu thng tin bng nhiu cch khc nhau. Vy x l nhng thng tin ny nh th no? y l mt vn khng h n gi n, nguyn tc quan trng nht l bit kt hp hi ha kin ca i tng s dng v ca chuyn gia thit k ti liu. i khi vic quyt nh sa mt vi t ng no li khng hon ton ph thuc vo tnh i din ca cc gp , m li ph thuc rt nhiu vo kin gp c gi tr hay khng, c ng cn nhc hay khng. Nu khng chc chn v ti liu sau khi sa, hy tip tc th nghim li ln na nu chng ta vn cn thi gian v kinh ph. Phi th nghim mt ti liu truyn thng nhiu ln trc khi in, tuy nhin khng nht thit phi th nghim vi c mu ging nhau trong cc ln th nghim.
2.3.7. Mt s ch khi thit k v sn xut ti liu in n

Vic thit k cc ti liu in n l c mt ngh thut, n i hi chuyn mn, kinh nghim v k nng. Phn ny ch trnh by mt s im chung nht khi xy dng cc ti liu. Kiu ch Kiu ch v vn phong to nn s r rng v ni dung truyn thng trong cc ti liu in. Nn chn kiu ch n gin, r nt. C th dng cc kiu ch in m, in nghing cho cc mc hoc nhn mnh. Khi la chn c ch, khong cch gia cc dng, gia cc ch, cn xem xt n i tng truyn thng. C ch to c th lm tng tnh d c, c th s dng truyn t thng tin ti nhng ngi c kh nng c km nh th lc km (ngi gi), ngi c trnh hc vn thp (nh dn tc thiu s hoc tr em). Tnh d c Tnh d c c hm cu trc cu ng ng php, n gin. Vit cu ngn, trnh by nhng on vn ngn (mi on ch gm 2-3 cu) c th gip lm tng tnh d c. Nn vit cu theo dng ch ng. Cu trc r ba phn m u (gii thiu), ni dung chnh (thn bi) v kt lun. Vn phong Cch hnh vn l mt yu t quan trng trong vic pht trin cc ti liu in n. Cch hnh vn i hi mt qu trnh hc hi, tch ly kinh nghim cng thm mt cht nng khiu vit. 78

Minh ha Vic s dng hnh nh minh ha c tc dng rt ln trong vic lm tng tnh hp dn, d c, d hiu. Hnh nh thng c s dng minh ha cho ch ca tng phn v minh ha cho nhng thng ip chnh. V d khi ni v v sinh c nhn, bn cnh cc thng ip nh: cn ra mt, nh rng vo mi bui sng, tt nht l c mt hnh v mt bn nh ang nh rng hoc ang ra mt vi cc dng c minh ha nh chu, bn chi, kem nh rng ... Cn c bit ch n vic s dng hnh nh minh ha trong truyn thng vi cc nhm i tng c kh nng c hn ch. Cch trnh by Vic thit k cch trnh by nhm lm cho c gi d c v d hiu nht. Cc hnh nh minh ha, cc mc, cc bng s liu, biu , phn on thng tin thng c s dng trong cc ti liu in n lm tng tnh d hiu v d c. C mt im cn lu trong cc ti liu in n l cn s dng nhng cu khi qut mi phn gip c gi c ci nhn tng th v phn . Bn cnh nhng ni dung chnh nn c tm tt v in m hoc nghing, thng ip chnh ca mi phn nn c in m bng kiu ch khc hoc c t vo trong khung.
5. CC TIP CN TRUYN THNGGIO DC SC KHE

Hot ng Truyn thng Gio dc sc khe (TT GDSK) c th c thc hin mt cch trc tip gia ngi lm TT-GDSK vi ngi dn / i tng. y l mt qu trnh lin tc trao i hoc chia s thng tin, tnh cm, k nng gia ngi lm TTGDSK vi mt c nhn hoc mt nhm ngi. V d: truyn thng trc tip hay c thc hin ti cng ng nh t chc ni chuyn v sc khe, tho lun nhm v sc khe, t vn hng dn cho c nhn v cc thnh vin trong h gia nh. TT GDSK trc tip c hiu qu nhanh trong vic lm thay i nhn thc, thay i hnh vi ca con ngi, c th gii quyt tha ng cc thc mc ca i tng. Ngi lm trc tip cng tc ny s c c hi hiu k lng nguyn nhn ct li ca vn c th c nhng gii php ph hp nht. H s c nhng bin php ng vin i tng quyt tm thay i hnh vi. Tuy nhin, phng php truyn thng trc tip thng hiu qu khi thc hin vi c nhn hoc mt nhm ngi. Bn cnh chng ta cng thng tin hnh cc hot ng truyn thng nhng khng giao tip trc tip gia ngi vi ngi m thng qua nhng phng tin truyn thng i chng v gi l cch tip cn hay phng php gin tip. Nhng ni dung di y s trnh by cch tip cn truyn thng vi c nhn, vi nhm v vi cng ng.
5.1. Tip cn truyn thng - gio dc sc kho vi c nhn 5.1.1. Ni chuyn v sc khe

y c th l hnh thc cung cp thng tin v sc khe, hng dn phng bnh, thc hin hoc thuyt phc mt ngi no thc hin nhng hnh vi c th. Qu trnh ny em li hiu qu cao. i tng c th tip thu, a ra cc cu hi thc mc 79

v nhn c phn hi ngay. Ngi lm TT-GDSK c th hiu c tm t, mong mun, thi , d nh ca i tng c k hoch truyn thng thch hp cho c cng ng. Ngoi ra, phng php GDSK trc tip ny cn c hnh thc c bit hn nh t vn sc khe l mt qu trnh tm hiu nhu cu ca i tng v kin thc, k nng, v s tr gip, sau cung cp nhng thng tin, hng dn, gii php v tr gip i tng la chn gii php thc hin gii quyt vn vng mc.
5.1.2. T vn sc khe

T vn l mt trong nhng cch tip cn thng dng nht trong gio dc sc kho i vi c nhn hoc vi gia nh. T vn l mt phng php v l ngh thut i hi cn b t vn phi c kin thc, k nng, s nhy cm khuyn khch ngi n t vn (i tng) by t c nhng vn ca mnh. Ri ngi t vn a ra cc gii php i tng c th la chn cho mnh mt gii php ti u ph hp vi iu kin, hon cnh ring ca ngi c t vn. V h l ngi quyt nh nn gii php la chn s thch hp v c duy tr. Nh vy, sau qu trnh t vn, i tng s t quyt nh cc la chn ca mnh ch khng phi do cn b t vn quyt nh. Mt s nguyn tc ca hot ng t vn l: cn to ra v duy tr mi quan h tt vi i tng; trn c s xc nh r nhu cu ca i tng; thu hiu v thng cm vi i tng; khuyn khch s tham gia ca i tng; tn trng v gia b mt cho i tng; cung cp thng tin v ngun h tr cho i tng. Qu trnh t vn gm cc bc chnh sau: Bc 1: To mi quan h tt v xc nh r nhu cu ca ngi c t vn Bc 2: Khm ph nhu cu v mi quan tm Bc 3: Gip c nhn sp t mc ch v xc nh cc la chn Bc 4: Gip i tng quyt nh la chn gii php thch hp nht cho vn ca mnh v thc hin theo quyt nh. Bc 5: Gip i tng pht trin k hoch hnh ng. Cn b t vn cn phi hiu c hon cnh v suy ngh ca i tng sau mi gip h xc nh nhu cu l g v chn gii php cho vn ca h. V vy, t vn c vai tr quan trng trong vic nng cao kin thc chm sc, bo v sc kho cho c nhn, gp phn cho vic NCSK v phng trnh bnh tt cho cng ng. T vn sc kho c th thc hin nhiu ni t cc c s y t (nh TTYT, bnh vin...), n nhng ni khc nh trng hc, cng s, h gia nh...
5.2. Tip cn truyn thng gio dc sc kho vi nhm 5.2.1. T chc ni chuyn v sc khe vi nhm

Bui ni chuyn v sc khe l mt hnh thc ph bin ti cng ng. Chng ta c th t chc mt bui ni chuyn ring, ni chuyn chuyn hoc c th lng ghp trong cc bui hp dn, cc bui hp tng kt, trin khai hot ng y t ti c s. 80

Trc khi ni chuyn v sc khe cn phi: Xc nh r ch ni chuyn: vic ny s gip ngi trnh by chun b tt ni dung cho bui ni chuyn. Xc nh r i tng (ngi nghe, ngi tham d): sau khi c ch ngi trnh by cn xem ngi nghe l nhng ai. Vic xc nh r i tng s gip chun b cch ni chuyn, cch tip cn v cung cp nhng thng tin cho tng i tng mt cch ph hp. Xc nh ni dung theo trt t cn trnh by. Xc nh thi gian cn trnh by bao lu. Vic ny gip ch ng v thi gian ni chuyn, phn b tng phn, tng ni dung mt cch thch hp. Chun b phng tin h tr thch hp. Nu ni chuyn vi nhiu ngi cn c micro, loa mi ngi nghe c r. Chun b thi im v a im ni chuyn ph hp. Chng ta s ni chuyn vo thi im no? Ni chuyn v tr no? Vic ny cng nn bn v hn trc vi ngi t chc ti a phng c s phi hp chun b gip bui ni chuyn c thun li. Khi ni chuyn cn phi: To ra mi quan h tt vi i tng thng qua vic cho hi, gii thiu r mc ch, ngha ca bui ni chuyn. Dng t, li ni r rng, d hiu ph hp vi a phng. Trnh by cc ni dung theo trt t logic, c s chun b. Kt hp s dng cc v d, phng tin minh ha. Quan st bao qut i tng iu chnh cch trnh by. Dnh thi gian ngi nghe c hi v tho lun nhng vn cha r. Gii p cc thc mc ca i tng mt cch y . Kt thc bui ni chuyn: Tm tt, nhn mnh cc ni dung chnh cho i tng d nh. C th kim tra li nhn thc ca i tng nu c iu kin. Cm n i tng trc khi kt thc.
5.2.2. T chc tho lun nhm v sc khe

Hnh thc gn ging nh ni chuyn vi nhm, nhng ngoi vic cung cp kin thc, k nng v mt ch sc khe no cn nhm tm hiu thm thng tin v kin thc, thi , thc hnh v mt ch sc khe c th; thun li, kh khn khi thc hin; nhng yu t lin quan n vn , cch gii quyt vn c c s lp k hoch can thip. 81

Mt s im cn thc hin trc khi tho lun nhm: Xc nh ch v ni dung tho lun nhm; Xc nh r mc tiu ca bui tho lun; Xc nh i tng tham d; Nn chun b th k ghi chp; Ch chn a im, thi gian thch hp. V d: Khi t chc tho lun nhm ngi dn tm hiu s hiu bit ca h v Bnh Lao v tuyn truyn cch phng bnh ny chng ta c th chun b cc cu hi tho lun nh sau: + + + + Bnh lao biu hin nh th no? Nguyn nhn ca bnh l g? Tc hi ca bnh lao l g? Tnh hnh bnh lao a phng ra sao? Cn lm g khi b bnh lao? Cn lm g phng bnh lao?

Khi tho lun nhm ngi iu hnh cn ch : Cho hi, lm quen, gii thiu v mnh; Gii thch r ngha, mc tiu ca bui tho lun; ng vin mi ngi tham gia tch cc; Tho lun ln lt cc cu hi theo trnh t chun b; To c hi, khuyn khch cho mi thnh vin tham gia tch cc v trao i; Khng p t ln t ngi tham gia v trnh mt s ngi c kin ln t thnh vin khc; Sau mi phn nn c tm tt, kt lun v yu cu thc hin nhng iu thng nht; Cm n i tng tham gia.
5.2.3. Gio dc sc khe vi gia nh

y l hnh thc ni chuyn v sc khe da trn cc vn sc khe cn gii quyt ti h gia nh. Thm gia nh ni chuyn v sc khe c cc u im sau: Xy dng mi quan h tnh cm tt vi cc thnh vin gia nh. Mi trng gn gi, quen thuc nn i tng c cm gic yn tm, d tip thu, ng thi c c hi v t tin trnh by kin, quan im ca mnh. Trc tip quan st c nhng biu hin lin quan n vn sc khe. a ra cc li khuyn st thc. 82

Trc khi n thm v ni chuyn v sc khe ti h gia nh nn thu thp mt s thng tin chung v h gia nh d nh n v hng xm xung quanh, ng thi hn trc vi gia nh v n vo thi gian thun li, thch hp. Khi n thm h gia nh: M u bng thm hi chung, nu r ngha, mc ch chuyn thm. Quan st nhanh mi trng gia nh, pht hin cc vn lin quan n sc khe. Thc hin ni chuyn, t vn gio dc v vn sc khe theo k hoch chun b. C th ni chuyn vi tng thnh vin hoc trao i chung tu tng ni dung. Pht hin nhng ngi m au bnh tt thm hi, t vn. C th gii thch v lm mt s cng vic lin quan. Kt thc thm h gia nh: Tm tt nhc li cc iu mu cht, nu thun li kim tra li nhn thc ca i tng v nhng thng tin va trao i. To iu kin gip gii quyt vn lin quan n sc khe ca gia nh. Cm n s hp tc ca gia nh.
5.3. Tip cn truyn thng gio dc sc kho vi cng ng

Thng c thc hin vi nhng hnh thc gin tip, c th ngi lm TTGDSK khng trc tip tip xc vi i tng, cc ni dung (thng ip truyn thng) c chuyn ti i tng thng qua cc phng tin TTC. Hin nay phng php ny c p dng ph bin v c tc dng tt trong tuyn truyn, cung cp cc thng tin v phng bnh, bo v sc khe, nng cao sc khe cho qung i qun chng nhn dn. Tuy nhin, vic p dng nhng phng php gin tip thng qua cc phng tin TTC thng c chi ph cao, mt khc y l hnh thc thng tin mt chiu nn cn phi c s lng ghp, phi hp vi cc hnh thc gio dc khc t c mc tiu v tng hiu qu ca gio dc sc khe. Cc hnh thc TT-GDSK vi cng ng, vi s ng i tng thng c tin hnh bng nhng chng trnh, nhng chin dch truyn thng nhn nhng ngy l, ngy k nim nhng s kin sc khe c th nh: ngy tim chng, ngy vitamin A (01/6), ngy th gii khng ht thuc l (31/5), ngy quc t phng chng HIV/AIDS (01/12).... Trong nhng chin dch ny, cc chng trnh sn khu ha nh: ca ma nhc, kch; thi vui c thng v cc ch sc khe c t chc nhm thu ht ng o cc thnh phn x hi tham gia. Trong cc chin dch truyn thng ny, mt s lng ln cc s nh, sch tham kho, t ri, cc ti liu truyn thng khc c phn pht cho nhiu ngi; treo nhiu bng rn, nhiu bng tin qung co ln ti nhng ni ng ngi to hiu ng truyn thng mnh m ti i tng. 83

6. CC PHNG PHP TRUYN THNG I CHNG

C nhiu cch phn loi cc phng php TTC, phn ny cp ba phng php ph bin l qung co, thng tin i chng v gio dc gii tr.
6.1. Qung co

Qung co l a nhng thng ip gii thiu v mt s vt, s kin, nhng hot ng c th trn nhiu phng tin TTC khc nhau v thng l phi tr cc chi ph cho n v qung co ni ring, c quan pht tin ni chung. Qung co thng l mt cu phn ca qu trnh xc tin trong chin dch tip th x hi nhm to n tng, thu ht s ch ca i tng ti mt sn phm c th nhm tng s tip cn v s dng sn phm ca khch hng. Trong lnh vc sc khe, hot ng qung co thng gii thiu cho ngi dn nhng sn phm c th nhm mc ch phng bnh, duy tr sc khe v nng cao sc khe, v d: qung co m bo him, bao cao su, thuc trnh thai, thuc b dng...
6.2. Truyn thng i chng

TTC l chuyn ti nhng thng ip trn phng tin TTC do cc c quan TTC tin hnh, v d: vic a tin trn cc chng trnh thi s, cc chuyn . TTC chuyn ti nhng vn , nhng cu chuyn hay nhng s kin nhm duy tr v nng cao nhn thc ca khn gi, tc ng thay i thi , hnh vi ca h i vi vn lin quan. Nhiu chin dch TTC hin nay ang s dng hnh thc hi ngh tng cng cc hot ng TTC. Trong nhng hi ngh chuyn ny, cc phng vin c mi n v nhn c nhng thng tin dnh cho bo ch, bng video, cc cuc phng vn v cc ti liu khc h tr nhng c quan ny pht tin v bi lin quan n ni dung, kt lun, khuyn co v ch no .
6.3. Gio dc gii tr

Gio dc gii tr l hnh thc gio dc thng qua cc hot ng gii tr. Tnh gii tr, hp dn, thoi mi ca nhng hot ng ny gp phn tng cng nhn thc, hiu bit, thi v k nng ca i tng v cc ch c th lin quan n sc khe. C rt nhiu hnh thc gio dc gii tr hin nay ang c s dng nh phim truyn hnh nhiu tp, gii tr trn truyn hnh nh " nh ch nht ", "Chic nn k diu ", Vt qua th thch... Nhng ch sc khe trong chng trnh ny c th to s thay i v kin thc, thi ca khn gi mt cch hiu qu.
6.4. La chn phng php truyn thng i chng

Vic la chn phng php TTC ph thuc vo nhiu yu t: Mc tiu ca chin dch Kinh ph sn c 84

 Mc tc ng n cc nhm i tng Mc phc tp ca cc thng ip Thi gian Quan h vi cc c quan TTC Cc phng tin truyn thng sn c. La chn v s dng phng php TTC da trn nguyn tc c nhiu u im v hn ch nhng nhc im (xem bng 8). Nhng chin dch TTC c s dng ph bin trong cch tip cn NCSK vi cng ng. m bo cho s thnh cng ca mt chin dch TTC cn ch n nhng yu t sau: C cn b c kinh nghim chuyn mn v sng to Tin hnh nghin cu trc chin dch hiu c nhu cu ca cc nhm i tng. t mc tiu c tnh kh thi Da vo mt m hnh l thuyt v thi , hnh vi sc khe Hng cc thng ip ph hp n cc i tng khc nhau Ch n tn sut tip cn vi thng ip ca i tng S dng nhiu phng tin truyn thng khc nhau S dng ngi pht tin, ngun tin ng tin cy To ra mt mi trng h tr cho vic thay i Hon cnh ph hp s dng cc phng tin TTC: mun tip cn nhiu i tng; trong thi gian ngn; mun vn c tho lun rng ri; nng cao nhn thc, hiu bit l mc ch chnh. Bng 1: u nhc im ca cc phng php truyn thng
Phng php Qung co u im Tip cn nhiu ngi Chi ph tnh theo s ngi nhn c v chu tc ng ca thng tin kh thp so vi truyn thng trc tip Kim sot c ni dung, tn sut thng ip Tip cn nhiu ngi trong thi gian ngn t tn km Tip cn nhiu ngi trong thi gian ngn C th tip cn nhng i tng khng thch thng ip Nhc im Tn km: chi ph thit k, sn xut thng ip, chi ph qung co

Thng tin i chng Gio dc gii tr

Thng t nhn c phn hi t pha i tng Thng tin c th khng chnh xc C th tn km

85

7. NHNG K NNG GIAO TIP

Khi tin hnh thc hin cc hot ng TT-GDSK, ngi lm cng tc ny cn rn luyn nng cao nhng k nng giao tip, k nng t vn c th hon thnh tt nhim v ca mnh. Mt s k nng c bn m ngi lm cng tc TT-GDSK cn phi c khi thc hin TT-GDSK c trnh by di y:
7.1. K nng lm quen

Cn cho hi thn mt, nu r l do v mc ch ca cuc gp g vi i tng. Cn ch n nhng c im tm l ca i tng c cch ng x thch hp.
7.2. K nng quan st

Quan st gip pht hin cc vn lin quan n vn sc khe. C th trao i gii quyt ngay mt s vn khi quan st c ti cng ng. Hn na, quan st cm nhn thi ca i tng iu chnh ng x.
7.3. K nng t cu hi

C hai loi cu hi, l cu hi ng v cu hi m. Khn kho, khng cho i tng bit l h b kim tra. t cu hi tp trung vo cc vn GDSK. Kt hp vi cu hi ng v m. B sung ngay cho i tng khi thiu ht. Khi t cu hi cn ch : Cu hi c r rng, d hiu cha? Cu hi phi ngn, khng cn phi gii thch cch tr li. C ph hp vi i tng khng? Tp trung vo vn trng tm. Sau khi t cu hi cn gi im lng. Ch nn hi tng cu hi mt. Nn hi xen k cu hi ng v cu hi m.
7.4. K nng lng nghe

Lng nghe ngha l khng ch nghe bng tai m phi nghe bng c mt, c ch, dng iu. Nhn vo mt ngi ni th hin thn thin, khch l ngi ni. Khng t ngt ngt li ngi ni. Khng lm vic khc, ni chuyn, nhn i ni khc. Kin tr, khng th hin s st rut kh chu.
7.5. K nng trnh by, gii thch

Trnh by nhng ni dung cn trao i r rng, theo trnh t, logic. S dng t ng d hiu, quen thuc vi i tng. Nm chc vn cn gii thch, gii thch y , r rng nhng cu hi, thc mc i tng nu ra. 86

Gii thch ngn gn, sc tch, s dng t ng d hiu. S dng cc v d v tranh nh, ti liu minh ha gii thch nu c. Gii thch tt c mi cu hi m i tng nu ra. Tn trng i tng, khng t thi coi thng h.
7.6. K nng s dng ti liu truyn thng gio dc sc kho

S dng cc ti liu c chnh thc lu hnh minh ha. S dng ng lc ng ch. Ch cho i tng thy r ti liu. Gii thch r theo cu trc logic ca ti liu.
7.7. K nng khuyn khch ng vin, khen ngi

Khng c ph phn nhng hiu bit, vic lm cha ng hay cha lm ca i tng. C gng tm ra nhng im tt ca i tng khen ngi d l nh. To mi iu kin tip tc h tr i tng thc hin thc hnh thay i hnh vi. TT-GDSK bng cc phng php a dng l can thip ch yu nhm thay i hnh vi c nhn. Chnh v vy cc cn b lm cng tc gio dc truyn thng cn xc nh c hnh vi c nhn nh hng n sc khe nh th no v yu t no nh hng n hnh vi. T vn dng cc l thuyt c bn v hnh vi vo nhng gii php can thip ph hp, ng thi tc ng iu chnh cc chnh sch, thay i mi trng to nn mt mi trng thun li cho c nhn thay i hnh vi.
Ni dung tho lun

Lm th no thc hin mt chng trnh TT-GDSK hiu qu cho mt vn sc khe ti a phng? Tai nn giao thng ang l mt vn y t cng cng Vit Nam hin nay. Mt trong cc nguyn nhn chnh l thc chp hnh lut giao thng ca ngi dn cn km. Bn hy phn tch cc yu t nh n thc chp hnh lut l giao thng ca ngi dn Vit Nam v ra cc hnh thc can thip truyn thng -gio dc ph hp.
TI LIU THAM KHO
1. Gochman DS., (1988). Health Behavior. Emerging Research Perspectives,

USA
2. John Hubley, (2004). Communicating Health. An action guide to Health

eduction and Health Promotion. 2nd Edition, MacMillan, p:47-65; 88-105; 127-163
3. John Kemn, Ann Close, (1995). Health Promotion - Theory and Practice.

MacMillan Press Ltd.

4. Linda E., Simnett I.,(1999). Promoting Health -A Practical Guide, London-

New York- Toronto. Fourth Ed.

5. Naidoo, J. and Wills, J. (2000). Health Promotion - Foundations for Practice

(2nd Ed), Harcourt Publishers Limited, London. 87

NH GI NHU CU SC KHO
MC TIU
1. Nu c khi nim v nhu cu sc khe v tm quan trng ca nh gi

nhu cu.
2. M t c cc dng nhu cu sc khe. 3. Trnh by c cc phng php v k nng cn thit trong nh gi nhu

cu.
4. Nu c cc bc ca nh gi nhu cu sc khe.

NI DUNG

Lp k hoch cho mt chng trnh NCSK l mt bc ht sc quan trng quyt nh s thnh cng ca chng trnh. Trong nh gi nhu cu sc khe l bc u tin ca qu trnh lp k hoch. nh gi nhu cu xc nh nhng g c nh n, nhm hay cng ng cn, cng h lp k hoch can thip gii quyt vn , ci thin tnh hnh mi trng theo hng thun li cho ngi dn phng bnh, bo v, duy tr v nng cao sc khe ca h.
1. KHI NIM NHU CU SC KHE

Nhu cu l iu m chng ta mun hoc cn b sung, l tnh trng hoc iu kin nu khng p ng c s hn ch, cn tr con ngi thc hin cc chc nng thng thng. Hay ni cch khc l s tho mn nhu cu s p ng cc chc nng ca con ngi trong cuc sng. Nhu cu cn c hiu l s khc bit gia nhng g ang tn ti v nhng g chng ta mong mun. Nhu cu sc khe l trng thi, iu kin hoc cc yu t m nu thiu n s cn tr con ngi t c mt trng thi hon ton thoi mi v th cht, tm thn v x hi. V d: vic cung cp cc dch v sc khe, mi trng an ton, hnh vi khe mnh ca c nhn v s tr gip ca x hi (Hawe, 2000). nh gi nhu cu sc khe l nghin cu c tnh h thng v cht lng cuc sng, tnh trng sc khe v cc yu t nh hng ti sc khe nh hnh vi sc khe v mi trng... (Bartholomew, 2000). nh gi nhu cu bao gm phn tch cc yu t nguy c v sinh l hc, hnh vi v mi trng nh hng ti sc khe, ngay c khi cc vn sc khe cha xut hin. V d: ung th phi l mt vn sc khe; nng nicotin trong mu cao l yu t nguy c sinh l hc; ht thuc l l hnh vi nguy c v mi trng lm vic cng thng, cuc sng c n l yu t mi trng nguy c. Nh th nh gi nhu cu

88

bao gm cc nghin cu xc nh cc hnh vi, tc ng ca cc yu t mi trng, x hi ti sc khe hoc cc nguy c sc khe. Thc hin nh gi nhu cu sc khe nhm: Xc nh cc vn sc khe ca cng ng. Xem xt cc nhu cu c bit ca cc nhm dn c kh khn, nhm d b tn thng hoc cc nhm dn c m nhu cu sc khe ca h cha c p ng y . V d: nhu cu thng tin sc khe bng ngn ng H'Mng ca nhm dn tc H'Mng; nhu cu m bo khu phn dinh dng trong ba n cho tr em suy dinh dng, nhu cu dch v k hoch ha gia nh cho cc ph n vng su - xa... Xc nh phm vi, mc trm trng ca vn sc khe. Xc nh nhm i tng ch m chng trnh can thip cn tc ng. C th ai l ngi chu tc ng nhiu nht bi vn sc khe ny. V d tr em vi vn suy dinh dng, ph n vi vn tai bin sau sinh... Xc nh cc yu t nguy c: hnh vi c nhn, yu t mi trng t nhin, kinh t, x hi, chnh sch, lut php, t chc... Xc nh cc ngun lc trong cng ng lp k hoch thc hin, can thip. C c s, bng chng xy dng mc tiu can thip v cc chin lc /gii php can thip thch hp.
2. CC DNG NHU CU 2.1. Nhu cu chun tc (normative need): c xc nh bi cc chuyn gia. Nhu

cu ny c th c iu chnh da theo nhng khuyn ngh t cc nghin cu khoa hc. V d: theo khuyn ngh ca cc nh khoa hc, tr 12-15 thng tui cn c tim chng nhc li vaccin Si.
2.2. Nhu cu c biu l (expressed need): L cc nhu cu c xc nh thng

qua quan st, nhn xt vic s dng cc dch v sc khe ca ngi dn. Vic xc nh cng c th da vo s liu thng k, danh sch khch hng ch cc dch v hoc phng vn nhng ngi cung cp dch v. V d: nhiu sn ph ng k sinh ti phng h sinh trung tm chng t ngi dn thay i thi quen la chn dch v sinh ti cc dch v y t c s. Tuy nhin, c th c cc cch l gii khng nht qun v nhu cu c biu l. V d, nhiu khch hng ch i ti mt dch v y t c th do nhu cu ca khch hng tng nhng cng c th do dch v qu chm.
2.3. Nhu cu cm nhn (felt need): L nhng g ngi dn cho bit h mun c hoc

ngh rng l nhng vn cn c gii quyt. Nhng phng php chung nh gi loi nhu cu ny l iu tra tm hiu quan im, kin ca ngi dn, hoc qua cc bui hp cng ng...
2.4. Nhu cu so snh (comparative need): c xc nh trn c s xem xt dch v

cung cp trong mt khu vc cho mt i tng c th v s dng dch v c bn 89

ny xc nh mt lot cc dch v cho i tng tng t trn mt khu vc khc. Nhng ngi nhn c dch v vi nhng ngi khng nhn c dch v. Ngi khng nhn c dch v c th c xc nh nh nhng ngi c nhu cu. V d ti a phng A, chng trnh cung cp nc sch c thc hin v ngi dn y c nc sch cho sinh hot. Tri li a phng B khng c cc hot ng trn v ng nhin nc sch l mt nhu cu a phng B.
3. CC BC THC HIN NH GI NHU CU SC KHO

Tin hnh nh gi nhu cu c c bc tranh ton din v nhng vn sc khe ca cng ng, t hng dn la chn nhng chng trnh can thip ph hp. Qu trnh nh gi nhu cu c th chia thnh 2 giai on chnh theo mc ch thu thp s liu trong tng giai on..
3.1 Giai on 1: Xc nh vn sc khe u tin

Mc ch l thu thp s liu v cn nhc nhiu kin quyt nh chn vn sc khe u tin. Phm vi, mc ca vn cn c ch r vi nhng chi tit lin quan ti nhm i tng ch. Giai on ny gm bn bc.
3.1.1. Bc 1: Trao i v bn bc vi cng ng

u tin l tip cn, ni chuyn v bn bc vi nhng ngi sng v lm vic trong cng ng ly thng tin lin quan m h cho l quan trng. Nhng g ngi dn quan tm, nhng vn sc khe no h cho rng cn phi gii quyt? nh gi tnh hnh sc khe ca cn b y t a phng. i tng lin quan n cc vn sc khe l ai? Tip cn cc t chc, dch v y t khc; cc ban ngnh on th; mng li cng tc vin; cc thy thuc t nhn; cc v ng ng u cng ng; cc gio vin ... thu thp thng tin, tm hiu, lm r cc vn lin quan. Cc hnh thc trao i c th l cc bui hp cng ng, tho lun nhm trng tm hoc phng vn. Ni chuyn vi cc lnh o hoc cc thnh vin c trch nhim trong cng ng. Ai s l ngi m bn cn tho lun hoc phng vn: Nhng ngi lm vic trong cng ng c hiu bit hoc c chuyn mn v nhng vn sc khe cng ng. V d: cc cn b y t a phng, nhn vin y t thn bn, cc thy thuc t nhn, ngi i din ca cc c quan, ban ngnh; ngi ng u cng ng (t trng dn ph, trng thn, cha o...); cc tnh nguyn vin, gio vin... Bn bc vi cng ng a ra nh gi chung v cc vn sc khe ang tn ti trong cng ng. Tuy nhin qu trnh tho lun khng phi lc no cng lun thnh cng. Nhng l do c th l mt s ngi cung cp thng tin c th khng ch ng tham gia vo qu trnh; cc kt qu tho lun c th b lng qun; thi gian hn ch, a im khng thun li lm cho cc thng tin thu thp c ngho nn; c th do ngi tham gia tho lun khng i din cho nhm i tng ch. Cn ch rng nhng ngi tham gia trao i c th by t cc quan im v kinh nghim khc nhau vi cc dng nhu cu 90

khc nhau. V vy cn theo di mt cch h thng trong khi trao i nh hng tm hiu su thm hoc trin khai cc bc tip theo.
3.1.2 Bc 2: Thu thp s liu, thng tin

S liu, thng tin c t nhiu ngun khc nhau. Chng gm nhng thng tin chung v kinh t, vn ha, x hi; thng tin lin quan n sc khe, cc dch v chm sc sc kho. Tm hiu nhng thng tin ny v c th tm hiu thm trn nhng i tng lin quan s gip chng ta xc nh cc vn sc khe, la chn vn sc khe u tin v xy dng k hoch can thip. Cc s liu, thng tin c lin quan n vn sc khe, cn thu thp thng l: Thng tin v dn s hc nh tui, gii, tnh trng gia nh.... Cc thng tin ny c th thu thp qua cc h s c lu gi c quan hnh chnh phng /x, qun/huyn; c quan y t cc cp Ch s v mi trng, kinh t v x hi nh: hc vn, hn nhn, ngh nghip, tnh trng tht nghip, nh ca, thu nhp, giao thng, cc vng cy xanh v vn nhim mi trng.... Tnh trng sc khe: t l bnh tt, t l cht; bnh dch; cc loi hnh chn thng; cc nguyn nhn t vong; bnh tt theo la tui, gii tnh, hoc khu vc. Cc s liu ny c th thu c t cc c quan y t cc cp. Kh nng p ng ca cc dch v sc khe v hiu qu hot ng ca nhng dch v ny. V d: khong cch t trm y t x ti khu dn c c thun tin cho dn khng? Cc dch v y t c th phc v ngi dn bt k thi gian no trong ngy khng? nh gi cht lng ca cc dch v bao gm xem xt kh nng, trnh ca nhn vin y t v cht lng c s h tng, dng c trang thit b... nh gi nhu cu sc khe cng cn xem xt ti cc chng trnh chm sc sc khe ang tn ti a phng, k c chng trnh quc gia hay chng trnh ang c cc t chc phi chnh ph tr gip. iu ny nhm huy ng ngun lc sn c v to nn mng li hot ng gm cc t chc c cng chc nng. nh gi kh nng ca cng ng v ngun lc trong k hoch chng trnh s ch ra s cn thit nng cao nng lc trong pht trin chng trnh v thc hin chng trnh. S dng cc s liu sn c Cc s liu sn c rt c ch trong vic xc nh cc vn sc khe. Cc s liu ny gm nhng nhm chnh sau: S liu nhn khu hc: dn s, t l theo gii, la tui, nhm dn tc... Cc ch s x hi: trnh hc vn, ngh nghip, tnh trng vic lm, thu nhp, tnh trng hn nhn, cc h tr x hi...

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 Cc s liu dch t hc: s phn b v cc yu t tc ng n bnh tt v chn thng trong qun th dn c. Nhng s liu ny gm: t l mi mc v hin mc, t l t vong, t l tn tt, nguyn nhn cht, t l sinh; cc yu t nguy c; tnh trng lm dng, bo lc; ngun lc phc v cho cng tc y t... Ngun cung cp s liu Cc s liu ny c th ly t cc h s c lu tr ti cc c s y t, c quan chnh quyn cc cp. Nhng ngi cung cp thng tin chnh ti cng ng, cc tp ch sc khe, cc bo co tng kt cng chnh l nhng ngun thng tin cn tip cn. Tuy nhin, khi s dng cc thng tin c sn cn xem xt s liu cha? Nhng thng tin g cn thu thp thm? tin cy ca cc thng tin thu thp c ra sao?
3.1.3. Bc 3: Gii thiu kt qu thu c

Nhng ngi ng gp thng tin v kin cho d n ca chng ta nn c mi n nghe thng bo v nhng kt qu thu c. Bn cng nn mi cc c nhn, t chc, nhng ngi ng vai tr tim nng trong vic hng dn, phi hp, tr gip khi thc hin chng trnh. S c mt v nhng ng gp ca cc thnh vin i din cho cng ng s gp phn khng nh chng trnh thc s v li ch ca cng ng. Khi gii thiu kt qu, nn trnh by r rng, n gin, d hiu cho ngi nghe tip thu v c th rt ra cc kin nhn xt, gp .
3.1.4. Bc 4: Xc nh vn sc khe u tin

Vi ngun lc hn ch, chng trnh khng th thit k tt c cc can thip gii quyt tt c cc nhu cu c xc nh trn. V vy cn xc nh vn sc khe u tin l g. Vic la chn vn sc kho u tin c th xem xt, cn nhc theo cc tiu ch sau: Mc ph bin: da vo cc ch s mi mc v ch s hin mc hoc vn c nh hng ti s ng dn c. Mc trm trng: vn sc khe gy nguy hi cho c nhn, nhm, cng ng nh th no? nh hng n cht lng cuc sng, tui th hay thit hi kinh t ra sao. Mc ny thng biu hin t l cht, t l tn tt, mc thit hi... Hiu qu can thip: c th thay i, ci thin vn bng cc can thip hay khng; chng ta c nhng chuyn gia thc hin can thip hay khng. V d cc hnh vi dng chung bm kim tim l mt trong nhng nguyn nhn gy lan truyn HIV. Hnh vi ny c th thay i bng cc can thip nh gio dc nng cao nhn thc v nguy c ca dng chung bm kim tim, hoc chng trnh trao i bm kim tim c th gim t l dng chung bm tim trong nhm ngi tim chch ma tu. Ngc li, cc bin php buc nhng ngi ny ngng thuc mt cch t ngt thng khng kh thi trong thi gian 92

ngn, hoc nu khng c nhng chuyn gia t vn th hiu qu thay i hnh vi cng rt thp. Mc quan tm ca cng ng: vn c tc ng n cng ng nh th no; ngi dn c sn sng, t nguyn tham gia hay khng; cc h tr x hi nh th no. C nhiu cch xc nh v la chn vn sc khe u tin nh: cho im theo su tiu ch (mc ph bin; mc trm trng; nh hng n nhm i tng kh khn; c cch gii quyt; kh nng kinh ph; tham gia ca cng ng) hoc tnh theo thang im u tin (mc ph bin, trm trng v hiu qu ca can thip) m WHO khuyn co p dng. Cch xc nh vn sc khe, chn vn sc khe u tin c trnh by k lng trong mn hc qun l h thng y t.
3.2. Giai on 2: Phn tch vn sc khe u tin

Vn sc khe u tin v nhm u tin c xc nh giai on 1. Giai on tip theo chng ta s phn tch vn sc khe u tin hng ti xc nh cc can thip ca chng trnh. Trc khi lp k hoch can thip chng ta cn phi hiu r cc yu t nh hng n vn sc khe v phi xc nh c cn thu thp thm thng tin g khng.
3.2.1. Bc 5: Nghin cu tng quan ti liu

Tng hp v xem xt k lng cc kt qu nghin cu c lin quan n vn cng b hiu r cc yu t quyt nh, cc yu t nguy c trc tip, gin tip ca vn sc khe chng ta ang quan tm. im li cc bo co v nhng kiu can thip c th nghim, tin hnh v t l thnh cng, ng thi xem xt nhng cn tr, nhng tn ti cn tip tc gii quyt. iu ny s gip chng ta thit k can thip ph hp gii quyt vn sc khe hiu qu. Sau khi nghin cu tng quan ti liu chng ta c th xc nh nhng thng tin lin quan cn thu thp thm.
3.2.2. Bc 6: M t nhm i tng ch

Chng ta cn phi m t mt cch chi tit i tng ch ca can thip. Nhng ch s lin quan gm cc c im nhn khu hc, cc ch s x hi nh: tui, gii tnh, dn tc, tn gio, hc vn, ngh nghip, ni c tr... Cc thng tin chi tit v nhm ch s l cn c xy dng k hoch can thip. Mt l do khc na l da trn nhng thng tin ny, nhng ngi lm NCSK khu vc khc c th so snh, cn nhc ra quyt nh v nhng can thip ca h.
3.2.3. Bc 7: Phn tch vn sc khe

Chng ta s tm hiu, xc nh mt lot thng tin theo cc nhm yu t lin quan, iu ny gip chng ta nh hng phm vi, mc v kiu can thip. Bng 9 s gip chng ta phn tch nhiu yu t lin quan n vn sc khe.

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Bng 9. Khung phn tch cc yu t lin quan n vn sc khe

Yu t C nhn X hi Mi trng Dch v y t Ti chnh Chnh tr Lut php V d Kin thc; thi ; nim tin; gi tr x hi; tnh t trng; s t ch; hnh vi c nhn Nhng hnh mu; h tr x hi; nhng mong mun; chun mc vn ha Mi trng t nhin; nhim; nh ; vn giao thng; ngun nc s dng Tnh sn c; kh nng tip cn; tnh nhy cm /kh nng chp nhn ca i tng ch Chi ph cho dch v y t, chm sc sc khe; c ch khuyn khch ti chnh cho cng tc phng bnh Nhng c hi cho s tham gia vo qu trnh ra quyt nh, hoch nh chnh sch; cc chnh sch y t v s cng bng trong chm sc sc khe. Nhng qui nh v an ton ni lm vic, lao ng; an ton v sinh thc phm; lut bo v mi trng; qui nh lin quan n qu trnh tip xc nhng vt liu c hi.

(Hawe P, Degeling D, Hall J, (2003). Evaluating Health Promtion)

3.2.4. Bc 8: Phn tch cc yu t nh hng (nguy c gin tip) n vn sc

khe Trong bc ny chng ta tip tc phn tch su hn cc yu t nh hng, cc yu t c coi l gin tip gp phn gy ra vn sc khe. y l nhng yu t nh: thiu iu kin hc hnh; kh khn trong vic tip cn dch v y t; khng c kh nng chi tr ph dch v, thiu s tr gip x hi... V d: Vn c thai i tng v thnh nin. Nhng yu t gin tip gy ra c th l: Khng s dng phng tin trnh thai Thiu kin thc v s dng phng tin trnh thai Kh khn trong vic mua phng tin trnh thai Gi phng tin trnh thai cao Tnh t trng thp Cm nhn tiu cc khi s dng phng tin trnh thai Tha mn nhu cu c nhn v vic c mt a con chm sc, nui nng Chng ta cng cn sp xp nhng yu t ny theo trnh t logic ca nhng nguyn nhn gy ra vn , iu ny c th gip chng ta phn loi cc nguyn nhn. u tin chng ta xc nh cc yu t c gi l cc du hiu ch im (risk marker). Cc yu t ny biu th ni xy ra vn , nhm i tng thng mc. Nhng yu t 94

ny thng khng trc tip gy ra vn . Theo v d trn, yu t ch im ca vn tr v thanh nin c thai l: thiu n tui 14-17; thuc nhm c i sng kinh t -x hi kh khn. Tip theo chng ta xp cc yu t nguy c theo trnh t. iu ny gp phn gii thch v sao xy ra vn . Trong v d trn yu t nguy c l quan h tnh dc nhng khng s dng bin php trnh thai. Bc th ba chng ta xem xt cc yu t gin tip, gp phn gy ra vn . y chnh l nhng yu t dn n cc yu t nguy c. V d cc yu t gp phn gy ra quan h tnh dc nhng khng s dng bin php trnh thai l: thiu hiu bit, chi ph cho phng tin trnh thai, nhng kh khn khi i mua, thi v s dng phng tin trnh thai, mun tr thnh ngi m... Nhim v tip theo l chng ta sp xp nhng yu t ny vo ba nhm chnh: nhng yu t tin , nhng yu t to iu kin thun li v nhng yu t cng c /tng cng ( cp chi tit trong bi 2). V sao nn sp xp theo ba nhm yu t nh vy? Bi v trong khi lp k hoch can thip chng ta thy rng tht kh c c s thay i v duy tr hnh vi mong mun nu chng ta khng tc ng vo c ba nhm yu t ny. Vic phn nhm nguyn nhn r rng s gip cho can thip c tnh ton din v hiu qu. V d: Vn c thai i tng v thnh nin. Yu t nguy c: quan h tnh dc nhng khng s dng bin php trnh thai. Cc yu t gin tip /gp phn: Nhm yu t tin : kin thc, thi v phng tin trnh thai Nhm yu t to iu kin thun li: phng tin trnh thai c gi cao; dch v cung cp /bn phng tin trnh thai khng thun tin Nhm yu t cng c /tng cng: gi tr, nim tin v s c thai la tui ny; vn ti chnh nhng b m tr c thn Cui cng chng ta cn xem xt, la chn cc c quan, t chc, cng ng c lin quan n vic tham gia lp k hoch v thc hin k hoch nh th no.
3.2.5. Bc 9: Xem xt li v tng cng cc ngun lc cng ng

Thc t c nhiu a phng sn sng chun b v trin khai hnh ng gii quyt cc nhu cu sc khe ca h. Ti nhng a phng m chng ta trin khai mt k hoch can thip mi, chng ta nn tm hiu r nhng ngun lc hin c, nhng chng trnh ang trin khai. Cc chng trnh can thip sc khe nn c s tham gia, phi hp cht ch vi cc thnh vin cng ng. Nh vy bn cnh vic xc nh nhu cu sc khe, chng ta nn tm hiu mt cch cn thn nng lc v sc mnh ca cng ng. iu ny th hin thng qua nhng kin thc, k nng chuyn mn, nhng bi hc thnh cng ca nhng chng trnh thc hin. Cng cn tm hiu s ng h, s tham gia ca cc c nhn, t chc thuc nhng nhm ch ca chng trnh can thip. Nh vy cui phn nh gi nhu cu chng ta cn c: 95

 Mt vn sc khe u tin c nht tr cao Ch r phm vi, mc ca vn sc khe Xc nh c nhm ch vi nhng c im c th xc nh r rng Mt lot cc yu t nguy c v cc yu t gin tip gp phn c xp theo nhm yu t tin , to iu kin thun li v tng cng Ch ra nhng ngun lc cng ng c th tham gia vo qu trnh can thip Cam kt t cng ng, t ngi thc hin chng trnh c c kt qu mong mun.
4. PHNG PHP THU THP THNG TIN

C nhiu cch thu thp thng tin khc nhau nh tm hiu ly s liu c sn trong h s, s sch lu tr; phng vn su nhng ngi cung cp thng tin chnh; phng vn hng lot i tng da vo bng cu hi chun b sn; quan st, ghi chp da vo cc bng kim. Cc phng php ny s c trnh by chi tit trong mn hc Nhn hc y t v Nghin cu sc khe cng ng, trong phn ny ch trnh by khi qut.
4.1. Phng php nh tnh

Quan st: L phng php thu thp thng tin bng cch theo di v phn tch hin tng. V d trc vn suy dinh dng tr em mt x, chng ta cn tm hiu ngun thc phm c cung cp, v th ch nn l ni u tin cho quan st. Cn xc nh thi im tt nht cho quan st, nu khng s c th cho cm nhn khng ng v hin tng. V d nu quan st hin tng n tc giao thng ngoi gi cao im s khng cho bc tranh tht v hin tng n tc giao thng trong thnh ph. C th trao i kin vi nhng ngi quan st khc trn cng mt i tng quan st c nhn xt hp l. C th mi mt s thnh vin cng quan st nhng hin tng din ra trong cng ng ca h, gip cng ng hiu r hn v vn m h ang i mt. Phng vn: Phng vn l cuc i thoi c mc ch v c chun b trc nhm thu thp nhng thng tin lin quan, cn thit i vi ch no , c bit l cc ch c tnh nhy cm. Ngi phng vn chun b v t cu hi ri ghi nhn nhng thng tin phn hi t ngi i thoi vi mnh. Trong qu trnh phng vn, c th khai thc, tm hiu thm mt s thng tin v kim tra li mt s thng tin cha r rng. Cn quan st nhng biu hin ca ngi tr li, cc yu t ca mi trng phng vn c th lm nh hng ti kt qu ca cuc phng vn iu chnh. K nng, phong cch ca ngi phng vn l yu t quan trng gip cuc phng vn t hiu qu. Tho lun nhm trng tm. Tho lun nhm i tng c cng mt s c im nhm trao i, bn lun v ly kin v mt ch quan tm. V d tho lun nhm ph n v ch gim s chp nhn ht thuc l ni cng cng, cng s v ti nh ... Tho lun nhm cho php mi ngi t do ni ra cc kin ca h v vn t ra, t ta c th rt ra nhng gi , nhng ch im cn tm hiu, nghin cu k lng hn. 96

y l phng php n gin thu thp thng tin ca nhm i tng ch. Tuy nhin khng cho php ta xc nh c phm vi, tm c ca vn . Cc phng php nh tnh cn s dng lm r hn cc kt qu nh lng. Thng tin nh tnh s gip hiu r hn cc yu t gp phn, cc yu t nguy c, nguyn nhn ca vn sc khe.
4.2. Phng php nh lng

iu tra trn mt mu qun th nht nh bng b cu hi chun b sn. Tng hp cc s liu thng k v dn s hc, dch t hc, cc trng hp mi mc, hin mc Kt qu nh lng cho php c lng phm vi, mc ca vn ; m t, c lng mc lin quan gia cc yu t phi nhim v nguy c. V d s liu iu tra cho thy t l ung th phi cao nhm ngi nghin ht thuc l v mi lin quan gia ht thuc l v ung th phi rt cht ch hoc hnh vi ht thuc l l nguy c ca ung th phi. Trong thc t, ty thuc cu hi nghin cu cn tr li, thit k nghin cu c th l nh tnh, nh lng hoc kt hp c nh tnh v nh lng. Kt qu nh tnh thu c c th l gi cho mt nghin cu nh lng hoc tm hiu su hn v mt vn m kt qu nh lng cha th hin c.
Bi tp thc hnh

Cc nghin cu trc y cho thy yu t gp phn, gin tip ca vn c thai n v thnh nin l do thiu kin thc v phng trnh thai v nh kin x hi vi vn ny. Hy xc nh nhm i tng u tin cn tm hiu? Thng tin no cn thu thp thm? Gi s yu t nguy c l khng i m bo him khi i xe my. Hy xc nh cc yu t gp phn dn n nguy c ny v sp xp theo cc nhm yu t tin , to iu kin thun li v tng cng.
TI LIU THAM KHO
1. Daniel S., Nelly E., Jose C., (1999). Participatory Rural Appraisal and

Planning, International Institute of Rural Reconstruction.

2. Bartholomew L.K., Parcel G.S., Kok G., Gottlieb N.H., (2000). Intervention

Mapping- Designing Theory and Evidence- Based Health Promotion Programs, London, Toronto.
3. Hawe P., Degeling D., Hall J., (2003). Evaluating Health Promotion,

MacLennan, Australia, p: 16-40.

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LP K HOCH CHNG TRNH NNG CAO SC KHO

MC TIU
1. Trnh by c khi nim v mc ch, mc tiu v chin lc. 2. Trnh by c cc tiu chun ca mc tiu v cc loi mc tiu. 3. Xy dng c cc mc tiu, chin lc cho mt chng trnh NCSK. 4. Lp c bn k hoch hnh ng cho chng trnh NCSK.

NI DUNG

Sau khi nh gi nhu cu, xc nh vn sc khe u tin v cc yu t nguy c, bc tip theo chng ta phi thc hin l xc nh mc ch, mc tiu v chin lc hay gii php gii quyt vn , ri lp k hoch hnh ng trin khai thc hin chng trnh GDSK n thun hoc chng trnh NCSK. y l cng vic quan trng gip nh hng v thc hin chng trnh hiu qu, v cng l c s cho vic theo di v nh gi chng trnh.
1. KHI NIM V MC CH, MC TIU 1.1. Mc ch

Theo T in ting Vit th mc ch l ci ch t ra hng ti. Mc ch thng l mt tuyn b chung v nhng g m mt chng trnh c gng t c. Mc ch c tnh i cng, bao hm mi kha cnh ca chng trnh v thng kh c th o lng chnh xc. t c mc ch cn phi thc hin v t c nhiu mc tiu v thng mt mt thi gian di. Mc ch ca chng trnh thng gm hai thnh phn quan trng l nhng kt qu mong mun cui cng cho cc i tng c lin quan. Trong nhng chng trnh sc khe, mc ch thng l nhng mong mun v s ci thin tnh trng sc khe cho nhm u tin hoc nhm i tng ch. Mc ch nhm gii quyt, thay i vn sc khe c phn tch bc nh gi nhu cu theo hng tch cc. V d: Vn sc khe l: T l suy dinh dng ca tr em di 5 tui l 35% ti tnh min ni X vo nm 2005. Chng trnh Phng chng suy dinh dng tr em c thit k vi mc ch l gim ti a t l suy dinh dng tr di 5 tui nhm ci thin tnh trng sc khe tr em ca tnh..
1.2. Mc tiu

Mc tiu l iu chng trnh can thip mong mun t c trong mt thi gian xc nh no . Mc tiu thng c din t c th hn mc ch v c v nh 98

chic cu ni gia nhng nhu cu sc khe v k hoch can thip. Mc tiu thng nhm gii quyt cc yu t nguy c c xc nh bc nh gi nhu cu. V d: yu t nguy c ca ung th phi l hnh vi ht thuc l, v th mc tiu ca chng trnh "Phng nga ung th phi" l gim t l ngi ht thuc. Mc tiu thng t c trc mc ch. Khc vi mc ch c tnh khi qut, mc tiu c tnh c th, c th; th hin mc c th o lng c. Mc tiu din t nhng thay i trong nhm u tin m chng trnh mong mun t c sau khi chng trnh kt thc. V d: Mc tiu: gim t l suy dinh dng tr di 5 tui t 30% hin nay xung cn 20% vo nm 2010 ti tnh X. i vi cc chng trnh GDSK th cc mc tiu GDSK c th chnh l nhng mc tiu thay i v kin thc, thi , hnh vi khng lnh mnh ca nhm i tng ch sau khi chng trnh hon thnh. V d: Kin thc, thi , thc hnh v nui dng con ca cc b m l cc yu t chnh nh hng ti tnh trng suy dinh dng tr em, vy mc tiu GDSK ca chng trnh phng chng suy dinh dng tr em l: Sau 6 thng thc hin chng trnh GDSK phng chng Suy dinh dng tr em di 5 tui, 95% b m c con di 5 tui ti tnh Y chun b c ba n ng khu phn dinh dng. Trong vng 12 thng thc hin chng trnh, 90% cc b m c con thi k n sam ti x A, huyn B, tnh C s dng vung thc n cung cp thc n hng ngy cho tr ng thnh phn dinh dng. Mt mc tiu GDSK c th ch nhm lm thay i nhn thc, thi , k nng hoc thay i c ba mt , v d: n cui thng 6 nm 2005, tt c b m trong x A nu c tm quan trng v s cn thit phi tim chng loi vaccin cho tr di 1 tui theo ng lch quy nh. n ht qu I nm 2005, tt c cc b m bit cch pha ORESOL cho con ung khi con b tiu chy. Trong nm hc 2005-2006, 100% hc sinh trong trng ph thng trung hc A khng ht thuc l.
1.3. Ti sao phi xy dng mc tiu trong gio dc sc kho?

Mc tiu l mc nh hng cc hot ng ca chng trnh phi thc hin t c. Xy dng mc tiu l mt bc quan trng ca lp k hoch. Mc tiu r rng gip ngi qun l, iu hnh thc hin chng trnh xc nh v cn i ngun lc tng xng. Mc tiu l c s la chn cc chin lc, gii php thc hin, v cho php chng ta gim st v nh gi quy trnh cng nh hiu qu ca chng trnh.

99

 Mt khc, cc ngun lc cho chm sc sc khe ni chung lun c hn, v th cng phi cn nhc xy dng mc tiu hp l da trn c s ngun lc tng tnh kh thi v hiu qu ca chng trnh. Trong qu trnh thc hin chng trnh th mc tiu nh hng vic iu hnh, theo di v gim st cc hot ng v c th iu chnh cc hot ng cho thch hp. Vic t ra mc tiu c th s kch thch v ng vin nhng ngi thc hin chng trnh phn u thc hin t c mc tiu v thi gian, s lng v cht lng. Mc tiu l c s t ra cc ch s nh gi kt qu ca chng trnh. bit chng trnh thnh cng hay tht bi phi so snh kt qu t c vi mc tiu ra. Khng c mc tiu cng s khng nh gi c cc mc t c ca chng trnh.
1.4. Tng quan gia xy dng mc ch, mc tiu ca chng trnh vi nh gi nhu cu

Mc ch chng trnh s nhm gii quyt vn sc khe c xc nh trong giai on nh gi nhu cu. Mc tiu chng trnh s nhm gii quyt cc yu t nguy c trc tip ca vn sc khe.. Mc tiu c th s nhm gii quyt cc yu t nh hng n, dn n yu t nguy c trc tip, v d: thiu kin thc, thiu nim tin... Mt s v d sau y minh ha mi lin quan gia mc ch, mc tiu, mc tiu c th vi vic phn tch vn sc khe. Bng 10. V d v tip xc vi tia t ngoi tr em
Vn sc khe Yu t nguy c (trc tip) Tr em trong trng hc tip xc vi tia t ngoi qu mc Tr khng i m khi ra nng Tr khng thch i m (yu t tin ) Nh trng khng cung cp m cho tr (yu t to iu kin thun li) M khng phi l phn thuc trang phc bt buc trong trng (yu t tng cng /cng c) Mc ch Gim mc tip xc vi nh nng mt tri hc sinh trong trng Tng t l tr i m khi ra nng Tng t l tr thch i m Cung cp m min ph cho hc sinh Bt buc hc sinh phi i m khi ra nng

Mc tiu Mc tiu c th 1

Nhng yu t gp phn (gin tip)

Mc tiu c th 2

Mc tiu c th 3

100

Bng 11. V d v chn thng do tai nn giao thng

Vn sc khe Chn thng do tai nn xe my tng Ngi iu khin xe my khng chp hnh ng cc quy nh v an ton giao thng Ngi iu khin xe my cha qua o to k nng li xe v lut giao thng Khng i m bo him khi i xe my Mc ch Gim t l chn thng do tai nn xe my Tng t l ngi iu khin xe my chp hnh nghim lut giao thng 100% ngi iu khin xe my c giy php li xe. 90% ngi iu khin xe my i m bo him

Yu t nguy c (trc tip)

Mc tiu

Mc tiu c th 1

Nhng yu t gp phn (gin tip)

Mc tiu c th 2

1.5. Cc bc vit mc tiu

Cn c vo cc thng tin c v kh nng ngun lc bao gm c thi gian xy dng mc tiu cho cc chng trnh NCSK c th. Khi xy dng mc tiu cn tham kho kin ca cng ng v cc i tc, cc c quan phi hp c th huy ng ti a s tham gia ca cng ng vo chng trnh v tng sc mnh, tng tnh kh thi ca chng trnh. Xy dng mc tiu cn qua ba bc sau:
1.5.1. Bc 1: Lit k ra cc mc tiu d nh

Sau khi xc nh mc ch ca chng trnh l nhm thay i, gii quyt vn sc khe, da theo cc yu t nguy c trc tip, cc yu t gp phn (nguy c gin tip) c phn loi trong phn trc, chng ta lit k hng lot cc yu t tng ng vi tng nhm. Nhng yu t ny c th l kt qu ca qu trnh phn tch vn trong phn nh gi nhu cu hoc t cc nghin cu khc. T chng ta c nhng tuyn b v nhng mc tiu tng ng. Chng ta c th minh ha bc ny qua v d v chn thng do tai nn giao thng nh sau: Bng 12. Vit mc tiu cho chng trnh phng nga tai nn giao thng Vn sc khe: Chn thng do tai nn xe my tng Mc ch: Gim t l chn thng do tai nn xe my
Yu t nguy c (trc tip) Ngi iu khin xe my khng chp hnh ng cc quy nh v an ton giao thng Cht lng ng km Cht lng n chiu sng, h thng ch dn km Mt phng tin tham gia giao thng qu ln Mc tiu Tng t l ngi iu khin xe my chp hnh nghim lut giao thng Ci thin cht lng ng Ci thin cht lng h thng chiu sng, h thng ch dn Gim mt phng tin tham gia

101

Nhng yu t gp phn (gin tip) Ngi iu khin xe my cha qua o to k nng li xe v lut giao thng H thng gim st, x pht cha nghim Khng s dng phng tin bo him nh: m bo him (xe my), ci dy an ton (xe t) Thiu tu b, nng cp ng Thiu kinh ph bo dng Thiu nhn lc, phng tin duy tr cht lng Thiu tnh phi hp, ng b ca cc c quan chc nng (giao thng, cnh st) Phn lung phng tin giao thng km

Mc tiu c th 100% ngi iu khin xe my c giy php li xe. 100% cc trng hp vi phm c x pht nghim Tng x % ngi s dng xe my i m bo him; y% ngi li t v hnh khch eo dy an ton Tng x % kinh ph nng cp, bo dng ng Tng y % nhn lc v phng tin duy tr bo dng cht lng ng Phi hp ng b cc ngnh cnh st v giao thng trong qun l h thng ch dn, nh sng Phn lung giao thng tt c nhng a im cn thit.

Cn ch tr li cc cu hi: Ai s l i tng u tin m chng trnh tc ng? i tng ch cn lm g c hnh vi lnh mnh? Yu t mi trng, x hi no cn tc ng to iu kin thay i hnh vi? Cn khong thi gian l bao lu i tng ch c s thay i. Chng trnh mong mun i tng ch thay i hnh vi n mc no? Vic nh ra mc thch hp v kh thi cho thay i hnh vi v ci thin sc khe ca i tng ch i hi cc nh lp k hoch phi xem li mc tiu ca cc chng trnh quc gia, nghin cu cc ti liu, bo co hin c, tnh n cc ngun lc c th huy ng cho chng trnh, bao gm ngun lc t ngnh y t, t cng ng v cc t chc khc.
1.5.2. Bc 2: Xem xt li cc mc tiu c lit k

C th nhiu mc tiu c nu ra, tuy nhin cng mt lc thng khng th gii quyt c mi vic. V vy chng ta xem xt li v la chn cc mc tiu c th gii quyt da vo nhng ngun lc v thi gian hin c nhm ci thin hnh vi c nhn, mi trng, cc yu t c nh hng ti vn sc khe c cp phn nh gi nhu cu v tng quan ti liu. Sau lc b bt cc mc tiu cha gii quyt c.
1.5.3. Bc 3: Chn ra cc mc tiu c tnh kh thi v iu chnh li nu cn

Chn ra cc mc tiu ch yu ph hp vi thi gian, ngun lc v phi p ng vic gii quyt cc yu t nguy c c xc nh bc nh gi nhu cu v tng 102

quan ti liu. Sau khi xy dng mc tiu, chng ta tip tc phi a ra cc chin lc v lp k hoch cc hot ng c th ca chng trnh nhm t mc tiu.
2. CC YU CU CA MC TIU

Mc tiu cn t c cc yu cu sau:
2.1. c th, c th

Mc tiu phi cp mt vn c th, lin quan n mt i tng ch c th ti mt a im xc nh. V d: ci thin kin thc ca cc b m v nui dng, chm sc tr gim tnh trng suy dinh dng tr em; tng t l ngi dn c kin thc v thc hnh ng phng bnh cm do virus H5N1.
2.2. o lng c

Mc tiu cn nu r mc thay i, c th so snh c vi mc ban u thy kt qu t c, c th nh gi c hiu qu ca chng trnh. S thnh cng ca chng trnh c th nh gi v s lng, cht lng v thi gian. Thc o mc t c c th l mt s lng c th, l t l phn trm, hoc bng mc nh tnh nh: tt, kh, trung bnh, km (c tiu chun nh gi cho tng mc c th).
2.3. C th t c hay kh thi

Mc tiu t ra phi c kh nng t c, tc l c tnh kh thi, ph hp vi cc iu kin, ngun lc hin c thc hin chng trnh. i vi cc chng trnh GDSK hoc NCSK, khi t mc tiu thay i hnh vi c nhn chng ta cn cn nhc hnh vi c d thay i hay khng trong mt khong thi gian nht nh. Tnh kh thi ca mc tiu rt quan trng. m bo kh nng thc thi th cn phn tch k lng nguyn nhn ca hnh vi sc khe, cc ngun lc c sn v cc ngun lc c th huy ng thc hin chng trnh.
2.4. Thch hp

Mc tiu phi ph hp vi cc vn sc khe c phn tch bc nh gi nhu cu. Cc mc tiu NCSK thng l nhm thay i cc hnh vi nguy c lin quan ti vn sc khe. V d: hnh vi tnh dc khng an ton nhm thanh nin l hnh vi nguy c ca cc bnh ly truyn qua ng tnh dc (STDs), nh vy mc tiu ca chng trnh phng chng STDs, HIV/AIDS c th l: "n thng 12/2005, 90% thanh nin c hnh vi tnh dc an ton....
2.5. Xc nh v thi gian

Chng ta mong mun vn c ci thin vo mt thi im nht nh, v th mc tiu chng trnh, cc hot ng c th u phi xc nh nhng khong thi gian tng ng, phi c nhng mc thi gian xc nh hon thnh. Thi gian c th cn gip chng ta tnh ton, cn i ngun lc thc hin. Thi gian xc nh cn gip ta c k hoch nh gi kt qu, hiu qu ca chng trnh. Nu khng xc nh ng thi 103

gian cn thit t mc tiu th s khng thc y c c gng t c mc tiu v c th gy lng ph ngun lc v thi gian. Hn na khong thi gian t khi bt u chng trnh n khi kt thc phi t c cc thay i mong i. V d: Sau 12 thng t khi bt u chng trnh tim chng, 95% b m c con di 5 tui a con i tim cc loi Vaccin phng bnh v ng lch ti x X, huyn Y. d nh, cc yu t cn t c ca mc tiu bn c th nh ch vit tt ca cc yu t trn: 2-3T (c th, t c, Thc thi (kh thi), Thch hp v Thi gian, hoc ch SMART ca ting Anh (Specific, Measurable, Achievable, Relevant, Time bound). Xy dng mc tiu cho chng trnh GDSK hoc NCSK l rt quan trng. Mc tiu nh hng cho mi chin lc v hot ng ca chng trnh. xy dng c mc tiu phi phn tch k cc thng tin c bn ban u v cc yu t c th nh hng n qu trnh t c mc tiu. Nh vy xy dng mc tiu ng v kh thi khng phi n gin. N i hi ngi tham gia phi c y kin thc v kinh nghim. m bo t c mc tiu, mt iu rt quan trng l cn thu ht cng ng tham gia xc nh nhu cu GDSK, NCSK, xy dng mc tiu v tham gia cc hot ng t mc tiu.
3. LA CHN CHIN LC /GII PHP THCH HP 3.1. Khi nim

Sau khi xc nh r mc tiu, bc tip theo l la chn cc chin lc hay cc gii php thch hp t c mc tiu chng trnh. Chin lc l cc phng php, cch thc tt nht t c mc tiu. V d: vn ng, pht trin chnh sch, o to, tp hun, truyn thng i chng...
3.2. Cc yu cu ca chin lc

Chin lc t ra phi ph hp vi nhm u tin: v d phng php truyn thng nhm nh hoc t vn gio dc i tng nguy c cao trong phng chng STDs, HIV/AIDS c th l bin php hiu qu vi i tng ny. Cn lu kh nng tc ng ti s ng i tng ch: v d truyn thng i chng (TTC). Chin lc thc hin chng trnh phi ph hp vi ngun lc, nng lc sn c v nhng ngun lc s huy ng ca t chc thc hin d n. Bn cnh n phi ph hp vi vn ha, phong tc tp qun, truyn thng v chun mc x hi a phng ni thc hin chng trnh NCSK. Cc chin lc t ra nn da theo cc chin lc NCSK chnh nu ra trong Hin chng Ottawa (1986) v Hin chng Bangkok (2005) nh: xy dng chnh sch y t lnh mnh, to mi trng thun li cho thay i hnh vi nh s tr gip ca x hi, tng cng cc iu kin vt cht k thut; nng cao vai tr cng ng, v d xy dng cng ng khng thuc l, trng hc khng khi thuc l; pht trin k nng c nhn, v d: o to nng cao trnh cho cn b y t thn bn, nng cao hiu bit v k nng phng ly nhim HIV/AIDS cho cc nhm nguy c cao. 104

3.3. Cc dng chin lc

Gio dc v o to: v d o to nng cao k nng lp k hoch, k nng t vn cho cn b y t thn bn... Truyn thng qua cc phng tin TTC... Truyn thng trc tip: v d t vn, truyn thng nhm nh Gio dc ng ng: v d nhm bn gip bn trong phng chng HIV/AIDS, STDs trong nhm tim chch ma tu, mi dm... Thit lp cc dch v h tr: v d thnh lp cc phng t vn cai nghin thuc l, t vn cc ch khc... Xy dng cc ni quy, qui nh tng cng, duy tr hnh vi lnh mnh. Pht trin ngun thng tin: xy dng cc trang bo in t, bo in, din n. Phi hp vi cc ban ngnh, t chc chuyn mn cng hot ng gii quyt vn Phi hp vi cc c quan TTC v c quan vn ha - x hi (Hi ph n, on thanh nin, Hi ch thp ...) ph cp kin thc, k nng bo v v chm sc sc khe cho ton th cng ng Hp tc vi cc c s gio dc ng trn a bn, lng ghp chng trnh GDSK vo ging dy trong nh trng Phi hp mi lc lng y t trn a bn (hi vin ch thp , cng tc vin dn s, nhng ngi tnh nguyn, y t t nhn, cn b y t v hu...), c phn cng trch nhim r rng, c hun luyn, o to k nng GDSK v s dng cc phng tin truyn thng
4. PHT TRIN CC HOT NG C TH THEO CC GII PHP

Khi xc nh r cc gii php thc hin, cng vic tip theo l lp ra bng k hoch hnh ng gm cc hot ng c th. Cc hot ng ny c pht trin t cc gii php tng ng. Khi lit k cc hot ng c th cn i chiu li mc tiu m bo l hot ng ph hp vi mc tiu, cng nh ph hp vi gii php. Nu cn thit c th iu chnh c mc tiu, gii php v hot ng c th cho hp l. Khi la chn cc hot ng cn cn nhc tnh kh thi v hiu qu. Nu hiu qu thp v /hoc kh thc hin th cn xem xt la chn cc hot ng tng ng thay th. Ty theo cc giai on thc hin, cc hot ng c th cn bao hm c cc hot ng gim st, theo di, nh gi nh k v kt thc chng trnh. Bng k hoch hnh ng c nhiu hnh thc, tuy nhin chng ta c th s dng mu bng thng dng nh sau:

105

Bng 13. Mu k hoch chng trnh NCSK Tiu bn k hoch: Mc tiu chung; Mc tiu c th Cc gii php Bng k hoch hnh ng
STT (1) Cc hot ng chnh (2) Thi gian (t ... n (3) Ngi thc hin (4) Ngi phi hp (5) Phng tin (6) Ngi gim st (7) Kinh ph (8) Kt qu mong mun (9)

5. XC NH NGUN LC THC HIN CHNG TRNH

Ngi lp k hoch cn xc nh r ngun lc no c v cn thm ngun lc no. Ngun lc c th bao gm con ngi, ti chnh, phng tin, cng c, thi gian, k nng, kinh nghim v s nhit tnh ca tt c cc i tng s tham gia chng trnh. Khi lp k hoch hnh ng c th cn xc nh nhng yu t c bn: Nhng ai s phi trc tip tham gia thc hin, nhng ai h tr, nhng ai l ngi cng tc. Trch nhim ca h c th nh th no. Trong nhng trng hp cn thit th mi ai phi hp gii quyt. Lu nhng ngi c tc ng tch cc n i tng ch c th mi phi hp khi cn nh: nhng tnh nguyn vin, bn thn, thy c gio, cha m, hi ph n, on thanh nin Cc chnh sch lin quan n chng trnh nh th no; c chng trnh no tng t ang din ra ti a phng khng. V d khi d nh trin khai chng trnh gio dc an ton tnh dc cho thanh nin ti a phng, chng ta cn tm hiu nhng chnh sch lin quan n GDSK gii tnh ang c thc hin a phng; c chng trnh v gio dc an ton tnh dc cha? Nu c, chng ta c th s dng nh nhng yu t thun li, bi hc kinh nghim trong lp k hoch, ng thi nghin cu trnh chng cho v cng xem xt tnh ph hp ca chng trnh. Xem xt cc dch v v phng tin sn c lp k hoch s dng trong chng trnh. V d huy ng cc phng khm nha khoa t nhn trong chng trnh phng chng cc bnh rng ming. Ngun ti liu: xem xt v tn dng cc ti liu truyn thng sn c nu cc ti liu c cng ch sc khe vi chng trnh ang c thc hin. 106

Bi tp thc hnh:

1. Chng trnh phng chng tc hi thuc l gim tc hi ca khi thuc i vi nhng ngi khng ht thuc ti ni cng cng (c th l ti cc qun ru ti tnh X). Cn b chng trnh xy dng mc ch ca chng trnh l: lm vic vi cc cc ch qun ru xy dng cc khu vc dnh ring cho ht thuc trong cc qun ru. Mc tiu ca chng trnh l: Tng nhn thc v tnh kh thi v li ch ca vic xy dng vng dnh ring ht thuc. 50% cc qun ru trong tnh xy dng cc vng dnh ring cho ngi ht thuc. Mc ch v mc tiu chng trnh c gii quyt c vn khng? Mc tiu chng trnh c p ng cc tiu chun ca mc tiu khng? Ti sao? 2. V.Q. l mt x thuc mt huyn ngoi thnh H Ni, 80% dn s ca x l lm ngh nng, ch yu l nui c v trng rau mu cung cp cho thnh ph. Nhn dn c phong tc dng phn ti chm sc rau mu. S liu v khm cha bnh ca trm y t x trong nhng nm gn y cho thy bnh c t l mc cao nht tr em di 5 tui vn l tiu chy. Trm y t x c nh xy dng k hoch GDSK/NCSK nhm lm gim t l mc bnh tiu chy tr em. L mt ngi c giao nhim v lp k hoch GDSK v phng chng tiu chy cho x V.Q, bn ngh cn thu thp thm nhng thng tin g xy dng mc tiu GDSK c tnh kh thi? Gi nh l bn c cc thng tin cn thit nh bn ngh cu hi trn, bn hy xy dng cc mc tiu GDSK v phng chng tiu chy cho x V.Q 3. Bn lun theo nhm xy dng mc ch v mc tiu cho cc chng trnh gii quyt nhng vn sc khe sau: T l suy dinh dng tr em di 5 tui cao ti tnh A T l st rt cao ti tnh B Tnh trng ly truyn HIV cao trong nhm tim trch ma tu ti tnh C
TI LIU THAM KHO
1. Bartholomew L.K., Parcel G.S., Kok G., Gottlieb N.H., (2000). Intervention

Mapping-Designing Theory Programs, London, Toronto Australia.

and

Evidence-Based

Health

Promotion

2. Hawe P., Degeling D., Hall J., (2000). Evaluating Health Promotion, 3. Naidoo J., Wills J., (2000). Health Promotion- Foundation for Practice Ed-

Sd, Bailliere Tindall.

107

NH GI CHNG TRNH NNG CAO SC KHE

MC TIU
1. Nu c khi nim v mc ch ca nh gi. 2. Phn bit c cc loi nh gi. 3. Trnh by c phng php v k nng cn thit thc hin nh gi mt

chng trnh gio dc sc khe.

4. Vit c cc cu hi chnh cho tng loi nh gi. 5. Xc nh c cc ch s cho tng loi nh gi.

NI DUNG

nh gi l cng vic cn thit xc nh chng trnh gio dc sc khe (GDSK), nng cao sc khe (NCSK) c c thc hin nh k hoch hay khng bi trong thc t tt c cc cng vic m nh k hoch d nh trn giy t u c th thay i. Ngun lc v vt lc c th bin i so vi nhng iu m nh k hoch d nh. Trong qu trnh thc hin c rt nhiu yu t nh hng n thnh cng ca chng trnh. nh gi s xc nh cc mc tiu v mc ch ca chng trnh c t c hay khng? nh gi cho bit phng tin, ti liu ca chng trnh c ph hp vi i tng u tin hay khng? Cc hot ng ca chng trnh c thc s din ra hay khng? Kt qu ca nh gi cng gip cc nh k hoch v thc hin chng trnh rt kinh nghim v iu chnh cho cc chng trnh tip theo. K hoch nh gi l bc cui cng ca k hoch chng trnh. Tuy nhin ngh v nh gi phi l cng vic song song vi k hoch v nh gi nhu cu. Chng ny s cung cp cch tip cn s dng trong nh gi chng trnh sc khe. Cc hnh thc nh gi v cc phng php s dng trong nh gi.
1. KHI NIM, MC CH NH GI 1.1. Khi nim

nh gi l qu trnh khng nh gi tr ca mt vt hay mt ti sn no . nh gi chng trnh sc khe l qu trnh xc nh kt qu t c ca mt hot ng hay mt lot cc hot ng ca mt chng trnh c thnh cng hay khng khi so snh vi cc mc tiu c xy dng trc. nh gi bao gm qu trnh o lng kt qu, hiu qu ca chng trnh. nh gi chng trnh thng lin quan ti cc bin php quan st, thu thp s liu xc nh chng trnh hot ng nh th no, so snh hiu qu ca chng trnh vi cc ch s ban u. 108

Mt vn kh khn trong nh gi l nh gi thng ch thc hin vo cui chng trnh. Trn thc t bn phi ngh bn s nh gi chng trnh ca bn nh th no ngay t khi lp k hoch. nh gi xc nh chng trnh c ph hp vi nng lc v ngun lc s dng khng.
1.2. Mc ch ca nh gi

nh gi chng trnh nhm: Xc nh chng trnh c c thc hin theo k hoch khng Xc nh chng trnh c t c mc tiu v mc ch khng. Xc nh yu t no nh hng n s thnh cng hay tht bi ca chng trnh. Rt ra bi hc kinh nghim thay i hoc iu chnh phng php nhm t c kt qu tt hn nhng chng trnh sau. nh gi ti liu truyn thng v phng php truyn thng s xc nh cc phng php v ti liu truyn thng c ph hp vi nhm u tin khng? C hp dn khn gi khng? c bit i vi cc d n th im c th nghim v cc gii php mi bn mun p dng vo ni khc. Bn phi nh gi c nhng tin b thc s do chng trnh gio dc sc khe qua vic s dng cc phng php thch hp rt kinh nghim cho cc chng trnh sau nhm trnh lng ph tin ca nu lp li cc phng php khng ph hp, khng c hiu qu. ng vin v lm tha mn cn b v nhng ngi tnh nguyn, nu chng trnh t c mc tiu ra. Cc ng nghip v nhng ngi khc c th cho l chng trnh gio dc khng c kt qu v bn cn phi c bng chng chng minh kt qu thuyt phc v tranh th s ng tnh h tr ca h. Bin gii cho vic s dng ngun lc bao gm ti chnh v nhn lc. nh gi chng trnh ch ra l bn tin hnh cng vic ca bn tng ng vi gi tr ca ngun lc. xc nh xem c phi iu chnh g v ngun lc tip nhn t c quan cung cp ti chnh. Nhng im cn ch khi thc hin nh gi: Khi nh gi bn cn t ra cu hi l v sao bn cn nh gi chng trnh gio dc sc khe, nh gi nhng ch s no v nh gi cho ai. nh gi cn nu ra c cc thay i no v ang din ra. Bn c th tin tng vi kt qu ca chng trnh n mc no? Bi cc thay i xy ra c th khng hon ton l do kt qu ca chng trnh gio dc sc khe m c th do cc yu t khc khng thuc can thip ca chng trnh. Thi gian bt u chng trnh n thi im thc hin nh gi phi i tng ch thay i hnh vi: v d sau 6, 9, 12 thng k t khi chng trnh bt u. 109

 Ngun lc l c th thc hin nh gi Cn thit phi c s tham gia ca cng ng trong nh gi. S tham gia ca cng ng gip hnh thnh mi quan h trch nhim vi cng ng: bn c th bit c suy ngh ca h v cc li ch v cc im yu ca cc hot ng truyn thng gio dc sc khe ca bn. Bn c th nh n kinh nghim ca h v hiu c nhng g v ang xy ra, nh gi tr thnh mt qu trnh hc hi, cng ng c th th hin cc kinh nghim ca h v lp k hoch cho cc hot ng trong tng lai.
2. CC LOI HNH NH GI 2.1. nh gi qu trnh (Process Evaluation)

nh gi qu trnh c lng cc hot ng ca chng trnh. nh gi cht lng ca cc hot ng v cc hot ng ca chng trnh ang tip cn n nhm no. nh gi tin thc hin chng trnh bao gm vic lng gi cc mc tiu trung gian, nhng g t c cho n thi im hin ti. Xy dng cc ch s nh gi cc mc tiu trung gian: v d nh ch s v tin cc hot ng trong chng trnh GDSK.
2.2. nh gi tc ng (Impact Evaluation)

nh gi tc ng c lng hiu qu trung gian ca chng trnh. i vi chng trnh GDSK, nh gi tc ng l c lng nhng thay i v hnh vi, kin thc thi m chng trnh GDSK mang li. Vic nh gi tc ng nh hng ca GDSK thng khng phi d dng v ngoi GDSK c nhiu tc ng khc n hnh vi sc khe ca c nhn cng nh ca cng ng. nh gi tc ng xc nh liu chng trnh c t c mc tiu ra hay khng? Ngi nh gi cn xc nh r cc ch s c th nh gi c cc mc thay i v kin thc, thi v hnh vi ca i tng v so snh vi mc tiu mong i nu ra. nh gi tc ng thng c thc hin ngay sau khi chng trnh kt thc. nh gi cc chng trnh GDSK bao gm vic a ra cc quyt nh quan trng. Cc thay i no cn c nh gi? Lm th no o lng c cc thay i ? Lm th no bn c th y mnh qu trnh thay i din ra nh l kt qu ca chng trnh? Trong lp k hoch nh gi cn a ra cc ch s o lng cc thay i m chng trnh mong mun t c. Hu ht mi ngi c th ng iu quan trng trong nh gi l phi ch ra c cc thay i xy ra. Nhng s cn thit ch ra cc thay i nh l kt qu ca chng trnh th thng khng r rng. Cn xem xt cc yu t hon cnh bn ngoi c nh hng n chng trnh GDSK nh v d sau:

110

 Tng t l tim chng l do B Y t trin khai chng trnh truyn thng i chng trn phm vi ton quc. nh hng ca cc c nhn trong cng ng do h c cc tng mi. Trong chin dch gio dc phng chng AIDS c mt ngi sao in nh no cht v AIDS v iu ny dn n cc hnh vi tnh dc an ton hn. T l tiu chy gim xung trong thi gian 4 thng ca chin dch gio dc sc khe, nhng tiu chy bnh thng cng c th gim trong giai on sau khi ma ma kt thc.
2.3. nh gi kt qu (Outcome Evaluation)

nh gi kt qu l c lng hiu qu ca chng trnh v mt lu di. nh gi kt qu xc nh liu mc ch ca chng trnh c t c hay khng. V d mc ch ca chng trnh GDSK nng cao kin thc v dinh dng tr em cho cc b m c con di 5 tui l l gim t l suy dinh dng tr em.
2.4. nh gi chi ph - hiu qu (Cost-Effectiveness Evaluation)

c lng cc kt qu t c c tng xng vi nhng n lc, ngun lc (Nhn lc, tin, c s vt cht, thi gian) b ra hay khng? so snh gi thnh v hiu qu thc ca chng trnh.
Mc ch o lng Mc tiu o lng Chin lc (hot ng) nh gi qu trnh nh gi tc ng nh gi kt qu

S 14. Mi lin h gia cc loi hnh nh gi vi mc ch - mc tiu v hot ng ca chng trnh

3. CC CU HI CHNH CN TR LI TRONG NH GI 3.1. nh gi qu trnh

Cn ch rng nh gi qu trnh ch bt u khi chng trnh c thc hin, nh gi qu trnh bao gm nh gi tt c cc hot ng ca chng trnh v bao gm nh gi cht lng ti liu, s tip cn ca chng trnh ti nhm u tin. Kt qu ca nh gi s gip ci thin v pht trin chng trnh tt hn. 111

C bn cu hi chnh cn c tr li trong nh gi qu trnh: Tt c cc hot ng ca chng trnh c thc s tip cn ti nhm u tin hay khng? Nhng ngi tham gia vo chng trnh c tho mn vi chng trnh hay khng? Tt c cc hot ng ca chng trnh c ang c thc hin hay khng? Cht lng ca cc ti liu truyn thng c ph hp v hp dn khn gi khng? Cc v d v cc ch s cn nh gi: S bui ging v an ton giao thng S hc sinh tham gia Thi im thng tin v an ton giao thng c chiu trn i truyn hnh Thng tin m nhm u tin thu nhn c t bi ging ti nh trng v qua knh truyn thng nh gi cc hot ng truyn thng: Mt cch tt nht l d kin c trc cc vn ca truyn thng vi cc mu th nghim cc i tng ch d kin trc khi tin hnh cc hot ng chnh. Tuy nhin vo cui chng trnh vn phi nh gi nh hng ca chng trnh nh th no. Nhng tht bi trong chng trnh truyn thng gio dc sc khe c th xy ra bt k giai on no ca qu trnh truyn thng. Nu bn t ra cc cu hi di y v tm s tht bi din ra giai on no ca qu trnh truyn thng bn c th khc phc c kh khn v y mnh chng trnh. Cu hi t ra khi nh gi cc hot ng truyn thng l: Cc hot ng truyn thng c c thc hin khng? + + + + + + + + Bao nhiu chng trnh truyn thng i chng c thc hin? Bao nhiu cc cuc ni chuyn/ o to c tin hnh? Bao nhiu cuc hp ca cng ng c t chc? Bao nhiu cc t ri c phn pht? Bao nhiu p phch c s dng?

Bao nhiu i tng ch nhn c cc thng ip? Bao nhiu, t l ngi xem c cc t p phch? Bao nhiu, t l ngi nghe c cc bi pht trn loa, i? Bao nhiu, t l ngi nghe cc bui ni chuyn? Bao nhiu, t l ngi n cc cuc trin lm?

Cc i tng ch c ch n cc hot ng truyn thng hay khng? 112

+ +

T l bao ph ca chng trnh nh th no? Bao nhiu ngi nghe c cc bi pht thanh, xem cc p phch, bao nhiu ngi ch trong cc cuc hp?

Cc i tng ch c hiu c cc thng ip hay khng? + Bao nhiu ngi c th nhc li ng cc thng ip trn cc p phch, chng trnh ca radio, cc bui ni chuyn, cc cuc hp vv.

Cc thng ip c thuyt phc c mi ngi khng? + Bao nhiu ngi chp nhn v tin tng vo cc thng ip? Bn cn phi rt thc t nh gi cc thay i din ra. Cc thay i trong nhn thc, hiu bit v nim tin c th din ra rt sm sau qu trnh truyn thng. Tuy nhin cc thay i v hnh vi v sc khe cn phi c thi gian di hn. Mt tng tt l cn phi nh gi ngn hn sm sau khi kt thc cc hot ng ca chng trnh v theo di sau nh gi cc thay i lu di din ra.
3.2. nh gi tc ng

nh gi tc ng tr li cu hi: Kin thc ca nhm c tc ng c c ci thin khng? Thi ca nhm c tc ng vi hnh vi khng khe mnh c thay i khng? Bao nhiu ngi thay i hnh vi sc khe hoc d nh thay i do kt qu ca cc hot ng truyn thng gio dc sc khe? c lng s ci thin kin thc ca nhm u tin hay i tng ch: Nhm i tng ch hiu bit c iu g? Mc hiu bit ca nhm i tng ch nh th no? c lng s ci thin thi : Nhm i tng ngh v mt hnh vi nguy c nh th no? V d i tng ngh g v hnh vi ht thuc l trong nh? ng hay khng ng ? Cm gic ca nhm i tng vi hnh vi nguy c nh th no? C th l rt lo lng v hu qu ca hnh vi nguy c, lo lng hoc khng lo lng c lng thay i hnh vi: nh gi thay i hnh vi c th bng cch quan st ci m i tng lm. V d quan st hnh vi i m bo him ca nhng ngi i xe my. nh gi thay i hnh vi c th bng cch iu tra qua b cu hi. V d bn thng lm g khi ht thuc trong nh gim tc hi ca khi thuc cho ngi xung quanh? 113

3.3. nh gi kt qu

nh gi kt qu nhm tr li cu hi : Cc hnh vi thay i c gp phn tng cng sc khe hay khng? T l i tng ci thin tnh trng sc khe do c hng li t chng trnh? Mc thay i ca ca t l bnh, t l mc bnh mi din ra nh th no?
4. PHNG PHP NH GI

nh gi cn ch ra c cc thay i din ra l do chng trnh ca bn. Nu nh mc tiu ca chng trnh r ngay t u th khng kh khn trong vic ch ra cc thay i trong cng ng. Tuy nhin chng minh cc thay i l do chng trnh ring ca bn th khng phi d dng v c cc l do khc. C hai phng php thng c s dng trong nh gi: Phng php nh tnh: Phng vn, tho lun nhm trng tm, quan st. Phng php nh tnh cho ta cc nhn xt su v ti sao kt qu li khng t c nh k hoch, hoc ti sao chng trnh t c mc tiu. Nhng kt qu thu c bng phng php nh tnh khng c tnh i din cho c qun th iu tra (tham kho thm phn nh gi nhu cu). Phng php nh lng: iu tra bng cu hi, bng kim, c s dng nhm i chng hoc khng. Phng php iu tra thc hin trn mt qun th nghin cu rng s xc nh c mc tc ng ca chng trnh v mc ci thin sc khe ca nhm i tng m chng trnh can thip. Tuy nhin cc s liu thu c t phng php nh lng li khng tr li c mt cch chi tit cc cu hi nh l do tht bi hay thnh cng ca chng trnh, nhng nguyn nhn su xa ca vn . Chng ta c th s dng c hai tip cn trn trong nh gi nhu cu sc khe v nh gi hiu qu chng trnh (Tham kho bi nh gi nhu cu sc kho). Cc o lng, phn tch kt qu t c c th da trn s so snh vi mt nhm i chng hoc so snh kt qu trc v sau khi thc hin chng trnh. S dng nhm i chng: Bn c th s dng nhm chng bng cch chn nhm chng cng ging vi nhm ch cng tt (v tui tc, v trnh vn ha, v ngh nghip, thu nhp...), nhm ny khng nhn chng trnh gio dc. Nu nhm can thip c c kt qu tt hn s l bng chng r rng th hin s thnh cng ca chng trnh truyn thng gio dc sc khe. nh gi gin tip khng c nhm chng (nh gi trc v sau can thip): Nu khng c kh nng la chn nhm chng th ta phi s dng phng php gin tip v loi tr cc l do khc dn n qu trnh thay i. Chng ta phi xem xt thn trng nhng g xy ra? Ta cn chn mu v phng vn cng ng v sao h c s thay i hnh vi? C phi v cc hot ng truyn thng GDSK hay khng hay v nhng l do khc m bn khng nhn thy? 114

iu tra c bn trc khi thc hin chng trnh

Thc hin cc can thip

nh gi sau can thip thay i kin thc, thi , thc hnh; tnh trng sc khe)

So snh
S 15. M hnh nh gi trc sau can thip

5. CHUN B CHO NH GI

Lp k hoch nh gi bao gm cc ni dung tm tt nh sau: Xc nh xem s nh gi ci g? La chn phng php nh gi no? C cn phi s dng nhm chng so snh khng? Chun b cc ch s c th o lng c v c kh nng thc hin nh gi mc thnh cng. Xem xt ngun nhn lc v cng ng khi xc nh mc tiu ca nh gi. Xem xt s thay i k c trong thi gian ngn v lu di. Khng ch gii hn tm hiu xem bn t c mc tiu ra cha m cn pht hin cc thnh cng ngoi d kin, cng nh cc vn khng mong mun xy ra. iu ny cng rt hu ch, l bi hc kinh nghim qu. Tm cch huy ng s tham gia ca cng ng tt c cc giai on ca nh gi bao gm t xc nh mc tiu, thu thp s liu, nh gi u ra v xc nh cc hot ng cho tng lai. Hc hi t thnh cng cng nh tht bi. Tm hiu ti sao chng trnh thnh cng hay tht bi v bi hc no c th rt ra. Chia s thnh cng cng nh tht bi ca bn vi nhng ngi khc. Tho lun vi h ci m bn lm, bo co v thng bo kt qu ca bn cho cc t tin tc v bo ch nu c th.
6. CC BC THC HIN NH GI CHNG TRNH GDSK, NCSK

Xc nh mc tiu nh gi Chn phng php nh gi: nh tnh, nh lng hoc kt hp c phng php nh tnh v nh lng Chn c mu Thit k v th nghim b cu hi, cng c nh gi 115

 iu tra, thu thp s liu, lm sch s liu X l v phn tch s liu Vit bo co Cng b kt qu. Bi tp thc hnh nh gi qu trnh, tc ng v kt qu Gi s chng trnh bn ang thc hin l: Gio dc sc khe trong nh trng ngn nga tai nn giao thng cho hc sinh ph thng. Mc ch ca chng trnh l gim t l tai nn giao thng trong tr em di 15 tui. Mc tiu ca chng trnh l 95% cc em hc sinh thc hin ng lut l giao thng. Chng trnh c cc hot ng l: Ni chuyn ngoi kha v an ton giao thng. Pht t ri truyn thng v an ton giao thng cho cc em hc sinh trong nh trng Truyn thng v an ton giao thng qua knh VTV1 i truyn hnh. Hy xc nh cc ch s nh gi qu trnh (hot ng), tc ng v kt qu ca chng trnh.
Bi tp thc hnh

Theo bi tp tnh hung phn nh gi nhu cu. Bn xc nh c vn sc khe u tin, v xy dng mc tiu cho chng trnh, bn hy xy dng cc ch s nh gi cho nh gi qu trnh, tc ng v kt qu v a ra phng php thc hin nh gi.
TI LIU THAM KHO
1. Green L., Kreuter M. (2000). Health Promotion Planning An Education and

Environment Approach, Mayfield Mountain Company, View- TorontoLondon.

2. Hawe P., Degeling D., Hall J. (2000). Evaluating Health promotion - Health

Workers Guide, Maclennan and Petty - Sydney, Philadelphia, London

3. Kemm, J. & Close, A. (1995). Health Promotion - Theory and Practice,

Macmillian Press LTD, London.

4. Naidoo, J. and Wills, J. (2000). Health Promotion - Foundations for Practice

(2nd Ed), Harcourt Publishers Limited, London.

116

117

Phn 3

Trin khai chng trnh Nng cao sc kho ti cng ng

118

PHT TRIN CNG NG TRONG NNG CAO SC KHO

MC TIU
1. Nu c khi nim v Cng ng v Pht trin cng ng (PTC) 2. Nu c mc tiu v ngha ca PTC trong Nng cao sc khe 3. Trnh by c cch tip cn PTC 4. Trnh by c cch thit k mt d n PTC

NI DUNG
1. KHI NIM CNG NG TRONG NNG CAO SC KHO 1.1. Khi nim cng ng

Trong y t cng cng (YTCC), khi nim cng ng c s dng rt ph bin v ng mt vai tr quan trng. i tng can thip ca YTCC l mt cng ng dn c khc vi i tng can thip ca y hc lm sng l cc c nhn n l. Hin nay c nhiu khi nim khc nhau v cng ng. Tuy nhin v cn bn, mt cng ng ny c phn bit vi cng ng khc bi nhng c trng ring no nh: yu t a l, vn ha, x hi, dn tc, tn gio ngh nghipTheo t in ting Vit ca Vin Ngn ng hc nm 2004 cng ng l: ton th nhng ngi cng sng, c nhng im ging nhau, gn b thnh mt khi trong sinh hot x hi. Trong bi hc ny chng ta hiu cng ng l: "mt nhm ngi c mi quan h, rng buc ln nhau do c chung mt hoc mt s c tnh nh: cng sng trong mt vng nht nh, cng mt dn tc, cng tn gio, chia s hoc c chung cc gi tr, chun mc hay mi quan tm". V d: cng ng ca mt lng, x, huyn, tnh no ; cng ng ngi Thin cha gio; cng ng ngi lm ngh gm s, cng ng dn tc HMng; cng ng nng thn, thnh th
1.2. c im ca cng ng

c im u tin phi k n khi nhc ti cng ng l yu t a l. Ni n cng ng l ni n mt tp th ngi nh c trn mt vng t ai c gii hn. Ranh gii a l c xc lp l c s phn bit cng ng ny vi cng ng khc. thc v a l l mt trong cc thc su sc v lu bn ca con ngi. V d: ngi cng qu, cng lng, cng x, ngi min xui, hay min ngc, ngi min bin hay min ni Yu t th hai l yu t kinh t: C s kinh t l yu t c bn quyt nh i sng x hi. Trong nhng hon cnh c th, con ngi khng th sng ring 119

bit m phi da vo nhau, cng chung sng, cng lao ng v cng hng th nhng thnh qu lao ng. Lc ny, cc hot ng kinh t khng ch to ra cho cng ng s m bo v mt vt cht m cn l mt phng din ca s pht trin cng ng. Mi ngi gn kt vi nhau trong mi quan h vic lm nh lng ngh... Yu t vn ha: y l mt nt c bit ca cng ng v l ht nhn bn vng gn kt con ngi vi cng ng. Cc yu t nh truyn thng lch s, cc gi tr v chun mc x hi, phong tc, tp qun, tn gio tn ngng l c s duy tr v pht trin mt cch bn vng i vi mi cng ng.
1.3. Khi nim pht trin cng ng trong nng cao sc khe 1.3.1. Mt s khi nim pht trin cng ng

Pht trin cng ng l mt qu trnh nng cao sc khe (NCSK) c s tham gia ca nhng ngi dn vo vic a ra cc quyt nh ca bn thn v cc yu t lin quan n sc khe. Ni cch khc, l vic cng vi mi ngi v cng ng to ra sc mnh v s t tin nhm gii quyt cc vn c tnh cp thit (Baum 1989). n nhng nm 1950, qu trnh PTC ni chung c m t l cc can thip ca chnh quyn di gc hun luyn nhng ngi lc hu nhng k thut tt hn h qun l t ai v sc khe bn thn, hoc khc phc nhng thiu ht trong lnh vc gio dc, sc khe v phc li (Dixon 1989). PTC trong NCSK l mt qu trnh qua mt cng ng xc nh c cc nhu cu v sc khe hoc mc tiu NCSK ca mnh, sp t th t u tin cho cc nhu cu hay mc tiu ny; nng cao s t tin v quyt tm trong cng ng, tm kim cc ngun lc bn trong v bn ngoi nhm gii quyt c nhng nhu cu v mc tiu ny; hnh thnh thi , hnh vi hp tc, phi hp trong cng ng theo chiu hng tch cc. (Ross 1955). Trong NCSK, PTC nhn mnh n tm quan trng ca vic tng tnh ch ng v t kim sot ca ngi dn nhm xc nh cc yu t nh hng n sc khe ca bn thn. Nng cao nhn thc ca cng ng i vi cc hnh vi c li hoc khng c li cho sc khe ca cng ng ni chung v ca bn thn ni ring. PTC mang ngha huy ng, khuyn khch s tham gia ca cng ng, ku gi s ng h ca nhng ngi ng u cng ng, khuyn khch tnh t lc v t nguyn trong cng ng. Tm li, PTC trong NCSK l mt tin trnh gii quyt vn sc khe, qua sc khe cng ng c ci thin nh nng cao kin thc v pht trin k nng pht hin nhu cu v vn sc khe, xc nh c cc vn u tin, huy ng c cc ngun lc a ra cc gii php v hnh ng thch hp. PTC thc cht l s tham gia ch ng vi t cch tp th ca ngi dn vo qu trnh NCSK ca c nhn v cng ng. 120

1.3.2. Mt s khi nim lin quan n PTC

S tham gia ca cng ng l s tham gia ca mi ngi trong cng ng n qu trnh xy dng mc tiu v thc hin cc hot ng nhm NCSK. Mc tham gia khc nhau ca cng ng c th hin s tham gia ca cc cp, ngnh, cc bn lin quan, t trung ng xung a phng, v ca chnh nhng ngi dn ti cng ng . V d nh vic tham gia ng gp kin ca ngi dn i vi cc iu lut bo v v chm sc sc khe hay s tham gia ca ngi dn vo chng trnh y t ti a phng (chng trnh tim chng m rng, chng trnh phng chng st rt, chng trnh phng chng lao v bnh phi ...). Hot ng ngoi tuyn l s m rng ca cc dch v chuyn mn n cc khu vc dn c sinh sng nhm gip cho cng ng d dng tip cn v s dng dch v y t. V d: cc nhm lu ng ca cc trm y t x i n tng bn lng pht hin v iu tr st rt, cc i lu ng ly mu xt nghim Lao ti cng ng, thc hin chng trnh tim chng m rng ti cc vng su, vng xa... D n y t cng ng l d n c thit k nhm p ng c cc nhu cu v sc khe trong cng ng. V d: d n phng chng suy dinh dng trong cng ng, d n nng cao thc cng ng trong phng chng tai nn, thng tch, d n gio dc sc khe v phng chng tc hi thuc l....
2. CC QUAN IM NH HNG pht trin cng ng 2.1. Quan im

PTC da trn cch tip cn t c s, xut pht t nhu cu thc t ca ngi dn. Mi ngi dn trong cng ng cn c nhn thc, hiu bit ng v thc hin nhng hnh vi lnh mnh nhm bo v, NCSK ca mnh v ca cng ng. S tham gia ca cng ng l quan im c bn ca PTC. Yu t t chc l ht sc quan trng. C quan Y t phi hp vi chnh quyn a phng, cng cc t chc, on th chnh tr, x hi (Mt trn t quc, Hi Ph n, Hi Nng dn, Hi Cu chin binh, on Thanh nin, Hi Ch Thp ...). Cn ng vin, h tr, huy ng ngi dn cng tham gia trong cc chng trnh sc khe cng ng. S tham gia ca chnh quyn c coi l nhn t bn trong, l mt thnh phn quan trng ca cng ng trong NCSK. Pht trin nng lc cho ngi dn bng cc chng trnh gio dc sc khe, o to k nng ph hp vi tng cng ng nhm tng cng kin thc, thay i thi v hnh vi, k nng thc hnh. T nng lc ca ngi dn s c cng c. Ni n pht trin cng ng, ngi ta thng cp n xy dng nng lc v trao quyn t ch cho ngi dn trong NCSK nhm gip ngi dn hiu bit, nhn thc ng tm quan trng ca cc d n sc khe trin khai ti cng ng, qua ngi dn tham gia tt hn vo cc hot ng NCSK ti cng ng. 121

2.2. Mc tiu ca pht trin cng ng

Hng ti ci thin v nng cao cht lng sng ca cng ng vi s cn bng v th cht v tinh thn bng cch thay i hnh vi sc khe mt cch tch cc. To s bnh ng tham gia ca cc nhm trong cng ng, bao gm c cc nhm thit thi. Tt c mi ngi u c quyn bnh ng nh nhau trong nhu cu v sc khe v tham gia vo cc hot ng chm sc NCSK. V d: trong cc d n gim tc hi trong phng chng HIV/AIDS, s tham gia ca cc nhm c nguy c cao nh tim chch ma tu, mi dm ng vai tr quan trng khi h tham gia lm cng tc gio dc ng ng hoc khi h ni ln ting ni ca mnh trong qu trnh thc hin chng trnh v nh gi cc hot ng can thip v phng chng HIV/AIDS. Thu ht s tham gia tch cc ca ngi dn vo qu trnh PTC v duy tr tnh bn vng ca qu trnh pht trin.
3. CCH TIP CN pht trin cng ng 3.1. Tp trung vo nhu cu sc khe ca cng ng

Khc vi cc vn u tin do cc nh chuyn mn xc nh ra, PTC bt u vi cc u tin sc khe, l nhu cu sc khe ca cng ng, c xc nh vi s tham gia tch cc ca cng ng v ph hp vi cng ng. Vi nhng nhu cu sc khe c xc nh, cc chng trnh nng cao sc khe c thit k v thc hin trn cng ng. Nhim v ca cn b y t cng ng l to ra mt bc tranh ton cnh v sc khe cng ng, xc nh c nhng c nhn, nhm ngi hoc ngun lc ng vai tr quyt nh trong cng ng. Cn b y t cng ng l ngi lin lc, tip xc vi ngi dn sng v lm vic ti cng ng nhm xc nh cc nhu cu v cng vi cc chuyn gia a ra cc gii php can thip.
3.2. Tp trung vo qu trnh nng cao sc kho

Qu trnh to iu kin cng nh nng lc gip cng ng ch ng NCSK ca mnh c coi l mt hot ng tch cc ca pht trin cng ng. l s tng cng tham gia ch ng, nng cao s t tin v tnh t ch ca ngi dn. Trong qu trnh , cn b y t cng ng ng mt vai tr thit yu trong vic khuyn khch s pht trin c nhn thng qua hot ng o to, hot ng nhm t h tr ln nhau; pht trin cc k nng vn ng hnh lang c chnh sch, s ng h tch cc hay lm vic vi cng ng huy ng ngun lc v s tham gia; h tr o to, pht trin ti liu o to...
3.3. Tp trung vo nhng nhm cng ng d b tn thng, kh khn

Qu trnh PTC u tin can thip trn nhng nhm cng ng kh khn, thit thi, d b tn thng nh cng ng dn tc thiu s min ni, vng su xa. Thay v 122

ch tp trung vo yu t li sng c nhn, PTC tp trung gii quyt nhng yu t x hi quyt nh sc khe. Mc ch chnh ca qu trnh ny l to ng lc v kh nng ngi dn cng hnh ng tc ng ln cc yu t nh hng n sc khe nh cc vn v vn ha, x hi, kinh t v mi trng. lm c iu ny, cc chng trnh sc khe cn: Tng cng cc hot ng tng cng sc khe i vi nhng nhm i tng thit thi, kh khn; Tng kh nng tip cn cc dch v y t ca nhm ngi ny; Cng c, nng cao trch nhim, bn phn ca dch v; Vn ng v i din cho nhng mi quan tm ca nhng nhm thit thi; Lm ni bt cc c trng ca cng ng v nhng nh hng i vi cc vn sc kho c th. Tip cn PTC l mt qu trnh lu di, phc tp. Qu trnh ny to ra trin vng thay i tnh trng sc khe cng ng nhng s gp khng t kh khn t c iu (bng 14). Bng 14. Thun li, kh khn ca tip cn PTC
Cc thun li ca PTC Bt u vi nhng quan tm ca ngi dn, v vy d t c s ng h ca mi ngi Tp trung vo cc nguyn nhn cn bn v cc yu t nh hng ti sc khe, khng da vo cc triu chng Nng cao nhn thc v cc nguyn nhn x hi ca vn sc khe Qu trnh tham gia ca cc bn lin quan s cho php /nng cao tnh t tin trong cng ng Qu trnh bao gm nhng k nng c th chuyn giao nh k nng giao tip, k nng vn ng hnh lang mc no , chnh nhng ngi dn trong cng ng cng s nh mt ngi cn b lm cng tc NCSK ti cng ng ca mnh. Cc kh khn ca PTC Tn nhiu thi gian, cng sc Cc kt qu thng khng r rng v kh nh lng Kh khn trong vic nh gi; Nu khng nh gi c, vic cp ngn sch s gp kh khn Cn b NCSK i khi kh x khi ng gia cng ng v c quan h lm vic Thng tp trung vo mt nhm dn c i khi cc vn a ra gii quyt mang tnh cc b a phng, thiu cc nh hng tng th

4. CC DNG HOT NG TRONG pht trin cng ng

C nhiu hot ng khc nhau c th hin trong PTC, nhng c nm dng hot ng c Smithies v Adams nu ra nh sau: 123

 S tham gia ca cng ng trong vic a ra quyt nh: Tng cng vai tr ca cng ng trong qu trnh a ra quyt nh, s tham gia ny c th nhiu mc t cao xung thp, nh iu hnh, trao quyn, t vn, thng bo... Hnh ng ca cng ng: Bt c hnh ng no ca cng ng nhm mc ch thay i mt iu g gp phn NCSK cng ng. V d: vic vn ng cc c quan chc nng cung cp cc dch v sc khe, dch v h tr khc nhm gii quyt cc nhu cu sc khe ca cng ng. Cc qu trnh to iu kin cho s tham gia ca cng ng: bao gm cc hot ng nhm tng cng cc k nng gip mi ngi tham gia mt cch ch ng v tch cc vo cc hot ng ca cng ng ni chung v NCSK ni ring. N bao gm vic cung cp cc kha o to ph hp, pht trin v h tr cc mng li trong cng ng. Quan h gia cc nh chuyn mn v cng ng: Trong pht trin cng ng, mi quan h gia nhng ngi lm cng tc sc khe v cng ng c dn cn c ci thin theo hng linh hot v ch ng t c hai pha, s thn thin v nim tin l yu t cn thit m bo tnh bn vng cho cc chng trnh sc khe ti cng ng. Hn th na, vic t chc chnh quyn ti a phng cng nhn quan h tch cc ny s l ng lc mnh m ngi dn t tin v ch ng hn trong vic by t cc nhu cu cng nh quan tm ca mnh i vi cng ng. H tr v mt chin lc: Bao gm cc chnh sch hay k hoch di hn hoc ngn hn v mt t chc, thc hin, nh gi cc chng trnh PTC. H tr chin lc c th nhiu cp , nh cng ng dn c, thnh ph, khu vc v quc gia.
5. PHT TRIN CNG NG V KH KHN TRONG THC TIN 5.1. Kh khn v ngn sch

Hu ht cc d n PTC c cp ngn sch thng qua cc c quan qun l nh nc, chng hn nh cc c quan ph trch v y t, gio dc. Mt s ngn sch c cp t cc ngun khc nhau bao gm ngn sch chnh ph v ngun ngn sch ku gi. Do vy c th s gp kh khn trong vic lp k hoch trin khai v nh gi nu ngn sch khng n nh. Ngn sch khng c m bo n nh khin cn b PTC chuyn t ch tp trung vo cc cng vic v PTC sang vic tm kim cc ngun ngn sch duy tr cc hot ng PTC.
5.2. Trch nhim ca nhn vin PTC

Cn b PTC c xem nh chic cu ni gia cng ng vi cc chng trnh nng cao sc khe, do vy, h c trch nhim kp trc cng ng cng nh chnh quyn a phng ni chung v n v y t ch qun ni ring v tnh hnh sc khe ca cng ng. 124

5.3. S chp thun ca c quan qun l

PTC l mt cng vic tn rt nhiu thi gian v ngun lc t c nhng kt qu mong mun. PTC c xu hng tp trung vo mt nhm cng ng nh trong khi cc nh chc trch c xu hng tp trung vo cc khi dn c ln. Vi tnh cht di hn, kt qu cha nhn thy ngay c ca PTC c th mu thun vi nhu cu t chc phn b ngun lc da trn nhng kt qu phn nh c bn. Nhng vn nh s phn bit trong cung cp dch v c th khng c nhng nh chc trch chp nhn.
5.4. Vai tr ca cc nh chuyn mn

Nhng ngi lm cng tc chuyn mn thng cho rng h l chuyn gia, l ngi hiu bit nht trong lnh vc m mnh chuyn su, ngc li cc cn b PTC coi vai tr ca h nh l cht xc tc hoc l ngi to iu kin cho ngi dn tham gia. Nhim v ca h l to iu kin cho cng ng by t nhng nhu cu ca mnh v h tr cng ng gii quyt c nhng nhu cu . Khi khng c s hiu nhau, thiu s thng nht v chc nng nhim v gia cc chuyn gia v nhn vin PTC c th ny sinh nhng kh khn trong hot ng.
6. GII THIU V THIT K D N PTC

D n PTC l mt k hoch hnh ng c s phi hp ca nhiu lc lng x hi nhm huy ng cc ngun lc, phn b chng mt cch hp l to ra cc sn phm hng ha v dch v x hi, t to ra nhng chuyn bin x hi ti cng ng. Qui trnh thit k c i theo logic gm nm bc: nhn din cng ng; xc nh nhu cu, xy dng mc tiu; xc nh ngun lc v tr ngi; xy dng k hoch hnh ng. Vi s tham gia ca ngi dn trong qu trnh thit k, khng nhng d n c nhng cn c thc t m cn c c hi ngi dn c th s hu ngay t u d n.
6.1. Nhn din cng ng

L qu trnh thu thp d liu u vo, l: cc d liu v kinh t, x hi, vn ha, gio dc, sc khe, v sinh, dinh dng ca cng ng, qua bc l nhng vn cn gii quyt.
6.2. nh gi nhu cu

L qu trnh xc nh cc nhu cu, sp xp u tin cc nhu cu, cn i v quyt nh p ng nhu cu no. Qu trnh ny c tin hnh qua cc cuc iu tra theo nhng thit k khoa hc. Mt s cch thu thp thng tin nh sau: Hi tho chuyn c s tham gia ca cc thnh vin trong cng ng. Tm hiu quan im ca cc t chc. Phng vn ngi dn, tip xc c nhn vi nhng ngi c uy tn trong cng ng 125

 Mi ngi dn tham d bui ni chuyn ca chuyn gia v PTC v t chc tho lun v nhu cu ca cng ng. Cc bui hp di hnh thc ng gp, trng cu kin.
6.3. Xy dng mc tiu

Mc tiu tng qut l mc ch cui cng ca d n l phng hng tng th cn vn ti ca tt c cc hot ng ca d n. Vic xc nh mc tiu tng th ph thuc vo cu hi nghin cu ca d n l g. Mc tiu c th: Tr li cu hi ci g? Lm ci g? Khi no lm? C th thc hin c khng? C th o lng c?
6.4. Lng gi ngun lc v tr ngi

Trong qu trnh thit k d n, cc cn b pht trin cng ng cn xc nh r cc ngun lc v nhng tr ngi lin quan n ti chnh (ti lc), c s vt cht (vt lc), con ngi (nhn lc) m bo tnh kh thi ca mt d n pht trin cng ng. Vic lng gi cc ngun lc cng nh tr ngi s gip cn b PTC tn dng mt cc ti u nht cc ngun lc ca cng ng, mt khc hn ch v tm cch gii quyt cc vn tn ti v c th gy cn tr n chng trnh PTC.
6.5. Xy dng k hoch hnh ng

y l qu trnh xc nh v la chn gii php can thip; xc nh cc hot ng c th ca d n; sp xp trnh t cho cc hot ng; xc nh thi gian cho cc hot ng; phn cng trch nhim thc hin cc hot ng cho tng thnh vin tham gia; d tr kinh ph v cc phng tin, cng c cho cc hot ng. Sau khi hon thin bn k hoch cc hot ng s c trin khai, qu trnh theo di, gim st v nh gi ng thi cng c thc hin theo k hoch ra. PTC trong NCSK l qu trnh tng th gip ngi dn NCSK cng nh dn nng cao cht lng cuc sng. PTC l mt chin lc c cng ng quc t v nhiu quc gia tha nhn. i vi cc cn b cng ng, y c coi l chin lc lu di, c tnh nhn vn nhm NCSK. Tuy nhin, trn thc t cng tc PTC c nhiu thch thc v vic nh gi hiu qu ca cng tc PTC gp nhiu kh khn. iu ny cn c gii quyt bng nhng h tr ca t chc chnh quyn, v quan trng hn c l s tham gia mt cch c thc ca chnh ngi dn ti cng ng.
Cc cu hi tho lun 1. Bn thuc v cc nhm cng ng no trong x hi? Phn tch nhng c

tnh c bn ca cc cng ng ny?

2. Bn hiu th no v PTC? Trong ni dung cng tc NCSK, chin lc

PTC ng vai tr quan trng nh th no? 126

3. Cn phi lm g tham gia v lm tt cc hot ng PTC? 4. D nh cho mt d n PTC trong tng lai ca bn nh th no?

TI LIU THAM KHO

1. Egger, Spark, Lawson, Donovan, (1999). Health promotion strategies and

method.
2. John Kemm, Ann Close (1995). Health Promotion-Theory and Practic.e 3. Jenie Naidoo, Jane Wills (2000). Health Promotion: Foundation for Practice.

Royal College of Nursing, p:199-216

127

NNG CAO SC KHO MT S C S

MC TIU
1. Trnh by c tm quan trng ca cc hot ng nng cao sc kho ti

trng hc, ti ni lm vic.

2. M t chng trnh nng cao sc khe tin hnh ti cc c s c th.

NI DUNG
Phn 1. NNG CAO SC KHO TRONG TRNG HC

Quan im trng hc c th tng cng sc khe v mang li nim vui cho tr c t lu. S pht trin ca dch v y t hc ng, s i hi cung cp nhng ba n v gio dc th cht l nhng th d chng minh trng hc c coi l mt mi trng quan trng nh th no trong vic khuyn khch chn la li sng c sc khe tt. Khi nim v mt trng hc tng cng sc khe l mt khi nim kh l mi m. Trng hc tng cng sc khe nhm thc hin c nhng li sng lnh mnh cho ton b hc sinh bng cch pht trin mi trng thun li, gp phn tng cng sc khe. Trng hc cung cp nhng c hi v cng i hi s tn ty v tnh cam kt cao cho vic cung cp mt mi trng th cht x hi tng cng sc khe v an ton (WHO 1993). Trng hc c coi nh l mt mi trng tng hp m trong c nhiu nhn t nh hng ti sc khe ca hc sinh v i ng gio vin gm: vic cch t chc hot ng ca trng hc, vic gio dc v nhng vn sc khe v vic cung cp nhng dch v y t v thuc men trong trng. Phn ny ni v s y v mt th cht, tinh thn v x hi ca tr em v cc trng hc c th tr thnh nhng ngi i din y quyn nng nh th no trong vic tng cng sc khe tt thng qua chng trnh ging dy v nhng bi luyn tp hng ngy. WHO coi sc khe nh l mt ti nguyn phc v cho s tn ti ca chng ta. Thnh tu gio dc cng l bc khi u ca tr em. Trng hc lnh mnh l mt mi trng hc tp tch cc c th gp phn cho vic nng cao thnh tu gio dc. Trng hc c coi l mt ni rt quan trng tin hnh cc hot ng nng cao sc khe, c bn l v trng hc lun c mt s lng rt ln hc sinh. Trong trng hc, hc sinh c hc v nhng kin thc ph thng, ngoi ra cn c hc nhiu ch lin quan n sc khe, thi , c ch v cch ng x gip cho tr hnh thnh nhng hnh vi c li cho sc khe ngay t khi cn nh. Giai on i hc l thi k c nhiu thay i v tm sinh l, hc sinh hnh thnh nhng c ch v thi quen m theo chng sut qung i. Nhng vn v hnh vi v sc khe thng pht sinh khi tr khng nhn thc ng v nhng yu t nguy c nh hng n sc kho. V thnh nin l mt nhm ngi d b nh hng bi bn b 128

cng trang la. Mi trng hc ng cung cp c hi giao tip vi cc bn b, cung cp nhng c hi hc hnh v mi trng an ton thc hnh nhng k nng mi. C chng c cho rng tr nh v thanh nin thc hin nhng hnh vi trong sinh hot gy nguy hi cho sc khe v dn dn thc hin hnh vi ny nh l mt thi quen. Tuy nhin, cng c nhng yu t kinh t, x hi v c nhn, nhng gi tr v chun mc vn ha nh hng n nhng quyt nh ca lp tr, nhng cch ng ph ca chng vi cc vn v sc khe. iu kin sng kh khn, thiu s ng h ca cng ng, cng nh kt qu hc tp khng tt c coi nh l nhng yu t c tc ng xu n sc khe ca tr. C mt mi quan h gia sc khe, gio dc v kh nng hc tp. Cuc sng ca tr trng hc nh hng ti s hnh thnh lng t trng v t nhn thc ca chng cng nh thi ng x ca chng. Hc sinh khng thch i hc, chm tin b thng c khuynh hng tp ht thuc, ung ru sm hn v thch tr thnh nhng ngi s dng ru v thuc l mt cch thng xuyn. Nu tr khe mnh, vic tip thu trong hc tp s nhanh hn, d hiu hn v tr thch th hn (WHO 1995). Theo WHO, mt nh trng trin khai cc hot ng NCSK c nhiu li ch: p dng c cc m hnh ton din v sc khe, trong bao gm nhng mi lin quan gia th cht, tinh thn, x hi v mi trng ca sc khe. Thu ht cc gia nh, ph huynh hc sinh thng qua vic khuyn khch h tham gia vo vic pht trin kin thc v k nng cho con em h. cao ngha ca mi trng t nhin nh: trng hc, nc sch, sn chi, cy xanh...gp phn lm cho tr an ton, khe mnh, to ra cc mi quan h x hi v mi trng hc tp tch cc. Lin kt cc dch v y t a phng v khu vc vi nh trng gii quyt nhng mi quan tm v sc khe c nh hng n hc sinh (nh: bnh giun sn, tt khc x, tt ct sng, sang chn tm l...). S tham gia ca hc sinh gp phn to ra nhng k nng lin quan n li sng lnh mnh v sc khe sut i. To iu kin nng cao s bnh ng v gio dc v sc khe bng cch nng cao cc nng lc lin quan n sc khe cho hc sinh n v ca ph n trong cng ng. To iu kin thun li cho nh trng v cng ng a phng cng phi hp vi nhau c nhng sng kin v sc khe em li li ch cho hc sinh, gia nh v x hi.
GII THIU V CNG TC Y T TRNG HC TI VIT NAM
1. V tr v tm quan trng ca y t trng hc

Hc sinh chim trn 25% dn s, thuc la tui tr, tng lai ca t nc, v th sc khe ca hc sinh hm nay c ngha l sc khe ca dn tc mai sau. 129

 Hc sinh thuc tui tr, ang ln nhanh v pht trin v mi mt, v vy mun c th h tng lai khe mnh phi ch t tui ny. Trn thc t a s bnh tui trng thnh u bt ngun t la tui hc ng nh: suy dinh dng, cn th, cong vo ct sng, bu c, lao, cc bnh tim mch, tiu ha, bnh truyn qua ng tnh dc Mi trng tp trung ng, tm thi l c hi lan nhanh cc bnh truyn nhim, nht l cc bnh dch nh: cm, si, quai b, au mt, bch hu, ho g, st xut huyt t trng ti gia nh v ton x hi (ba mi trng). Hc sinh l cu ni hu hiu nht gia ba mi trng, nn nu cc em c chm sc, gio dc v mt sc khe s c nh hng tch cc ti c ba mi trng. Trng hc l ni gio dc ton din cho th h tr, cho nn lm tt cng tc sc khe cng c ngha l lm tt cc ni dung gio dc khc nh: c, tr, th, m, lao ng. Y t trng hc phi l cng tc quan trng hng u trong s nghip gio dc sc khe th h tr v quan trng ngang vi cc ni dung khc ca nh trng, nhm thc hin khu hiu: tr em hm nay - th gii ngy mai, tt c v tng lai con em chng ta, tt c v hc sinh thn yu!
2. NI DUNG CHNH CA Y T TRNG HC 2.1. V sinh hc ng

Gm c: v sinh c nhn, v sinh trng s, v sinh mi trng, v sinh ch hc v sinh hot, v sinh hc phm, v sinh trang phc hc ng, v sinh an ton thc phm V sinh c nhn: v sinh thn th v trang phc, li sng lnh mnh, t bit chm sc sc khe cho bn thn, v sinh tui dy th V sinh trng s: quy cch xy dng trng s m bo an ton, sch p, chiu sng v hp l, thong kh, chng tc hi ca thi tit, hc c v ph hp vi tm vc, sp xp ng, to ni hc, rn luyn, vui chi, lao ng thun tin nht hc tt, dy tt v phng nga cc bnh v tai nn, ch yu l 2 bnh hc ng: cn th v cong vo ct sng. V sinh hot: m bo tt sinh hot gia hc v chi, nht l trong nm hc, ch nht ngy l, ngy ngh Tt v cc thng h hc tt v sc khe cng tt. V sinh mi trng: ch yu qun l, gii quyt tt phn, rc, nc thi, kh thi trong trng, quan tm trng cy xanh, hoa v thm c, m bo ung nc tinh khit v trng, dng bp un khng khi, lc nc lm trong nc, st rc c np y, sn chi bi tp sch, thong mt, t bi v an ton, thi tt nc ma v nc sinh hot hng ngy, khng ng. V sinh ch hc v sinh hot: sp xp hp l thi kha biu, u tin cho hc sinh nh, chng hc ca ba, vui chi gii tr tt nht, ngh ngi y , v 130

hp l (ngh ngi tch cc v ch ng), chng hc go, hc khng ngh v ng thiu, tn trng cc quy nh ca B Gio dc v o to v ch hc v thi c. V sinh hc phm: m bo hc phm an ton, sch p, thun tin cho vic hc tp v hon ton thng nht vi B Gio Dc v o to hc i i vi hnh. Phi hp tt nht gia nh trng v gia nh cng cc nh sn xut, ni cung cp hc phm cho hc sinh tng cp nh: v, bt, cp, ch, phn, thc. V trang phc: m bo thc gi gn v sinh trang phc cho hc sinh, ng thi phi hp vi nh trng v ni sn xut to trang phc hc ng ph hp theo tm l v sinh l tui, gii, thi tit, cu trc c th ngi Vit Nam, p v d ph cp rng ri. V sinh an ton thc phm: m bo n ung sch, an ton khng mc cc bnh cp tnh (ng c, tiu chy, d ng) v cc bnh mn tnh do ha cht c v cc mm bnh (virus, vi khun, k sinh trng, nm mc), gio dc trong v sinh n, ung cho hc sinh, m bo n cht dinh dng, tiu ha tt, phng chng suy dinh dng, bo ph, bnh rng ming, bnh ng tiu ha, bnh ung th
2.2. Phng cc bnh truyn nhim gy dch

Gm bn loi bnh sau: Bnh truyn qua ng h hp (qua nc bt, nc mi) nh cm, st cao, vim hng, bch hu, ho g, st pht ban, thu u, au mt , quai b, vim mng no (phng bnh ch yu l v sinh khng kh v thc hc sinh khi ho, ht hi, khc nh, ci to, ni to). Bnh truyn qua ng tiu ha (qua nc v thc phm) nh: t, l, thng hn, bi lit, tiu chy, giun sn, vim gan A (phng bnh ch yu) l: v sinh n ung v thc phm, v sinh dng c n ung gia bnh nhn v ngi lnh, v sinh bp, cng tin). Bnh truyn qua ng mu (do vt trung gian truyn t mu ngi c mang mm bnh sang ngi lnh nh mui hay b cht t, dng c y t khng tit trng k, quan h tnh dc khng an ton) nh cc bnh truyn qua ng tnh dc, k c HIV/AIDS, st xut huyt, vim no, vim gan B, bnh giun ch Bnh truyn qua ng da nim mc (do tip xc trc tip) nh bnh di (ch yu do ch di cn), un vn, nhit thn, au mt , gh, chy rn Ch : Pht hin sm - cch ly kp thi v ng n, bao vy dp tt nhanh, khng ly lan v gy tc hi ln n hc tp, ging dy, n ngi v ca. St trng, ty u nhng ni nghi ng theo hng dn ca c quan v sinh phng dch.
2.3. Phng cc bnh thng gp khc

Gm c hai loi (t chng trnh y t c lin quan v t cc bnh v t nn trong tui hc ng trong tng giai on v tng ni to ra do giao lu quc t v s tin ha ca x hi). 131

 Cc chng trnh cn s phi hp ca y t trng hc gm: chng tiu chy (CDD), tim chng m rng (EPI), chng nhim khun ng h hp (ARI), phng chng HIV/AIDS, cc bnh ly qua ng tnh dc, bnh bu c, phong, mt ht, st rt, thp tim, suy dinh dng, thiu vi cht (iod, vitamin A, fluor), v sinh an ton thc phm, nc sch v v sinh mi trng (WATSAN), giun sn, ma tu hc ng, lao, k hoch ha gia nh (sinh c k hoch) sc khe sinh sn (cho tui v thnh nin). Cc bnh thng gy ra trong la tui hc sinh (ch yu trong thnh ph theo m hnh cc nc cng nghip) nh quan h tnh dc sm, c thai v lm m sm, no ph thai, cc bnh truyn nhim ly qua ng tnh dc (HIV/AIDS, lu, giang mai, h cam), nghin ma tu, dng cc cht kch thch mnh (gy hoang tng, kch dc, bo lc), ri lon nhn cch, sa st v tm thn: nh ni di, b nh i lang thang, n cp hoc cp git, git ngi, hip dm, th dm, ri lon kinh nguyt, ng tnh luyn i, t vn, xm mnh, li c nhu cu lm p khc nh: nhum tc, phu thut thm m, phu thut chnh hnh, tp luyn, trang im, cng cc gii php khc. Cho nn Php hin nay c 5000 6000 hc sinh c 1 trung tm gm c: 1 bc s, 2 y t, 2 tr l x hi (ti liu y t hc ng Php - 1998). Ngoi ra cn hai bnh ph bin l hai bnh hc ng: cn th v cong vo ct sng m ta cn tp trung lm tt. Mun gii quyt cn bn bin php sau: Gio dc phng trnh, nu r c ch v tc hi ca bnh v hnh vi (theo tui v gii). T chc tt mng li gim st ca trng v bit pht hin sm. C phng y t v nhn vin y t cn lm thm t vn sc khe, nu cn mi thm 1 n gio vin hay cn b on c kinh nghim v uy tn vi cc em. C hnh thc khen, ph v phi hp cht ch vi gia nh v cc t chc hu quan.
2.4. Chm sc rng ming (chng trnh Nha hc ng)

T chc ny tuy c c bit cao trong TP. H Ch Minh v cc tnh pha nam, nhng cn hiu r l n nm trong y t hc ng chung ch khng tch bit, bn ni dung cn qun trit l: Gio dc v sinh rng ming (dy cch chn bn chi, kem nh rng, cch chi rng ng, thc v sinh trong n ung nga su rng, vim nu nh: trnh n nhiu cht ngt, cc bt dnh hoc cn cc vt cng, chn thc n ph hp, trnh dng nhiu nc lnh c ngy, hiu bit y v cc cht lm chc rng l cht fluor). T chc sc ming dung dch fluor 0,2% hng tun cho hc sinh tiu hc (v l tui bt u mc rng vnh vin) cn bo v lu di.

132

 T chc khm rng nh k 6 thng/1 ln pht hin sm, cha tr kp thi phng v tr bnh ngay t ban u, s khng c bin chng v bo v c lu. Trm bt cc h rnh trn mt nhai nga su rng v bo tn c lu. Phn u gim t l su rng, vim li cho tui hc ng khe, p, hc tt, nga nhiu bin chng.
2.5. S cp cu ban u

Nhm x tr ngay ti ch, sm nht cc tai nn cng cc bin chng do tai nn gy ra nh: chy mu, gy xng, bong gn, sai khp, ngt xu, ngt, in git, cht ui, bng, ng c do thuc, do c cht, do n ung, h ng mu, ch cn, rn cn, say nng, cm lnh, cm nng, d vt ri vo mt, nghn, d vt ng th, nn ma, tiu chy cp, d ng, au mt, au bng, au u v khp, nhim trng ngoi da, ng kinh Gii php l phi c nhn vin cp cu thng trc ti trng, c ti thiu cc loi thuc men v cc loi trang thit b y t trong phng y t trng hc. lm tt cc yu cu trn cn lu nm im sau cho mi trng hc: Phi t chc ban y t trng hc ca trng do gim hiu lm trng ban. Nhn vin y t lm thng trc trong thi gian hc sinh c mt ti trng, thm cn b on, i, mt s hc sinh ln, i din ph huynh hc sinh v i din hi ch thp ca trng. Phi c phng y t (trong c nha hc ng) vi cc trang b ti thiu. Ngi c giao ph trch phng ny phi c hc tp, bi dng hng nm thnh tho cng tc chuyn mn v nghip v, bit cch qun l cng vic. Phi c vn bn, ti liu v y t trng hc do hai B son tho hoc ban y t trng hc thnh ph hng dn bit m phn u xy dng trng tin tin v y t trng hc hay trng hc nng cao sc khe (Health Promoting School) nh cc nc quen dng, lm ng chc nng, ng khoa hc v sinh v s phm, tit kim cng qu v c s ng gp ti a ca nh trng, gia nh v cng ng ni trng ng. Phi da vo ngun ti chnh ch yu l s ng gp ca ph huynh v bo him y t v c trch 35% tng s tin thu c cho hot ng y t trng hc ca trng m ch yu l: trang thit b, thuc men phc v hc sinh. Phi lun coi trng cng tc tuyn truyn gio dc sc khe v cng tc o to, hun luyn cho mng li v sinh vin, hi vin ch thp ca trng, cng tc thi ua khen thng v ngc li c x l thch ng i vi cc trng hp vi phm. Tiu chun thi ua v mt v sinh hc ng - y t hc ng cn phi lng ghp vo tiu chun thi ua 2 tt th mi trnh c mu thun v mi c hiu lc. Cn phi hp, lng ghp cc chng trnh y t nhm tng hiu qu ca mi chng trnh, li tit kim c thi gian, nhn lc, kinh ph.

133

Y t trng hc lm tt nhm mc tiu: hc tt, dy tt, sc khe tt cho ng o hc sinh v c gio vin, cn b cng nhn vin ca nh trng to ra tc ng tch cc ti mi gia nh v ton x hi.
3. NHIM V CA NHN VIN Y T TI TRNG HC 1. Xy dng k hoch hot ng y t cho nm hc, trnh lnh o ph duyt v

t chc thc hin.

2. S cu v x l ban u cc bnh thng thng, qun l t thuc v y dng

c.
3. T chc thc hin khm sc khe nh k, qun l h s sc khe ca hc

sinh v gio vin.

4. T chc trin khai cc chng trnh y t a vo trng hc. 5. Tham mu cho lnh o nh trng ch o thc hin cc yu cu v sinh

hc ng, v sinh mi trng trong nh trng, v sinh an ton thc phm, v sinh khu vc ni tr, bn tr theo cc quy nh ban hnh ca B Y t, B Gio dc o to, ni quy ca nh trng.
6. Tham gia cc lp o to bi dng v y t hc ng do ngnh y t t chc

cng cc yu cu do y t hc ng cp huyn, qun ra.

7. S kt, tng kt cng tc y t trng hc, bo co thng k y t hc ng

theo quy nh.

4. MI NGHIP V QUN L Y T TRNG HC 4.1. Tuyn truyn vn ng

Tuyn truyn ci g? Tuyn truyn ch trng, ng li, chnh sch v y t trng hc cng cc yu cu chuyn mn, nht l cc iu l v sinh hc ng mi ngi cng hiu, ng tnh cng lm v lm cho tht tt. Tuyn truyn cho ai? Lnh o cc ban ngnh c lin quan nh: y t, gio dc, hi ch thp , ph n, thanh nin, cc ban ngnh, on th a phng, hi cha m hc sinh h gip , cng tc, t chc thc hin hay ni chung l: x hi ha cng tc y t hc ng. Vn ng ai v lm g? Nhng ngi c tm huyt vi sc khe th h tr, cc nh doanh nghip c sn phm phc v hc sinh nh: cp, v, bt, giy dp, trang phc hc ng, chi, m phm, kem v bn chi rng, nc ngt, bnh ko, cc thuc, ngha l rt rng. Cc Mnh thng qun trong nc v ngoi nc. H c th gip ta kinh ph, vt t, ti liu, sn phm cng nhiu th khc trn nguyn tc: cng c li v khng i ngc ch trng chung ca nh nc v vi mc tiu ca gio dc. Tuyn truyn vn ng bng cch no? Trc tip nh: Ti ni gii thch, i vn ng, ni chuyn hoc gin tip qua mi knh truyn thng m ta c nh: 134

tivi, i bo, t chc cc cuc thi, cc chin dch c ng, v d nh chin dch sch xanh thnh ph.
4.2. o to - hun luyn chuyn mn nghip v

Cho mng li chuyn trch cc huyn, qun. Cho mng li cc trng (chuyn trch v bn chuyn trch thng gi l gio vin kim nhim). T chc o to trong h cho mng li chuyn mn nh: nha s, cc y s chung, bc s, y t : gii mt vic bit nhiu vic. Mun vy phi nm vng mng li, trnh v c k hoch chi tit o to hng nm. Cho lnh o cc ban ngnh, on th, nht l cc trng v tm quan trng ca y t trng hc cng mt s yu cu c lin quan cn h tr ca h nh: kinh ph, xin bin ch, xin c s vt cht, hoc cho php a tiu chun y t trng hc vo cc im thi ua nh gi chung ton trng hoc ton ngnh, v sc khe cng l mt trong cc mc tiu phn u ca ngnh Gio dc v o to. Thi gian o to thun li l trong h, v mi gio vin u c thi gian bi dng chuyn mn, nghip v trong mt thng h.
4.3. T chc mng li

Cn thnh lp ban y t trng hc hay ban sc khe trng hc cp tnh, thnh ri qun, huyn, cui cng l ban sc khe trng hc. cp tnh, huyn th trng ban nn l v ph ch tch ph trch vn ha x hi, ph ban l i din hai s hay hai phng (hoc trung tm) y t v gio dc, song ngi th k thng trc l quan trng nht. trng th trng ban nn l gim hiu, ph ban thng trc l nhn vin y t chuyn trch hay kim nhim. Ban ny cn c i din ph huynh hc sinh, v y l lc lng h tr c lc nhiu vic cho y t trng hc. Mng li cng nn c thm thnh vin ch thp v on thanh nin v hi ch thp c ban thanh thiu nin ch thp trng hc vi ni dung hot ng sc khe v v sinh y t trng hc chng ta.
4.4. Sinh hot

c t chc th phi c sinh hot iu hnh v duy tr, pht trin t chc . Ban y t trng hc (thnh ph hay tnh) cn quy nh lch sinh hot ni b trong ban (nn l hng thng vi nhm th k v hng qu vi ton ban), lch sinh hot vi qun, huyn (nn l hng qu) v gip cp di sp xp lch sinh hot cho bn thn h. Nn sinh hot vi cp trn hay ni b trc ri mi sinh hot vi cp di cho st. Ni chung mi nm hc nn sinh hot nh sau: Thng 8 chun b cho nm hc mi. Thng 12 s kt hc k 1, c k hoch cho tt nguyn n v hc k 2. Thng 6 tng kt nm hc (trong c tt v hc k 2) ra k hoch h. Ch khi sinh hot phi c chun b k ni dung, trnh hi ht, rng tuch s kh duy tr sinh hot v sau. C nhn xt thi ua qua mi k sinh hot v kt qu ny a vo tng kt nm hc.

135

4.5. Bo co

C ba loi bo co sau: Bo co thng k (hc k, nm hc) theo mu ca B ri tnh chi tit gi cho c s, hn ngy np th mi c s liu chnh xc c, v th phi c mu thng nht. Bo co t xut c chia hai loi: t xut t yu cu thu thp mt chuyn g hay khi c thin tai, dch bnh xy ra v t xut t di bo ln khi c tai nn hay mt yu cu gp no . Ni chung bo co cn c mu v hn ng ngy np t di ln, v d mun bo co ln B vo thng 6 th tnh phi c bo co t qun, huyn t cui thng 5, qun huyn phi c bo co t c s vo u thng 5 th mi chun b kp. Tuyt i trnh tnh trng ba s liu.
4.6. Thanh tra - kim tra

Thanh tra khi c yu cu khn cp nh khi c tai nn, dch bnh, c khiu ni hay vi phm cc nguyn tc v sinh an ton gy bnh dch hay tai nn cn x l, cn kim tra ch yu l ng vin, thi ua. C ba loi kim tra l: kim tra thng k gp , thng vo u nm hc. Kim tra xp loi thi ua, khen thng khi s, tng kt, thng vo cui hc k v kim tra t xut khi c yu cu hay s c xy ra. Khi i kim tra cn c on ti thiu ba ngi, c bin bn ghi chp gi li c s, c th bo trc hoc khng bo trc tu loi kim tra, v d gp th nn bo trc.
4.7. Chn v ch o im

Nn la chn m hnh mu, m hnh hot ng thnh cng nhn rng. Ni chung mi tnh nn c im: mt qun im, mt huyn im. Trong qun, huyn li nn c cc trng im nh: mu gio, tiu hc, trung hc c s v ph thng trung hc. Cng c th chn im v y t trng hc hay ring tng chuyn mc nh v sinh mi trng, chiu sng v hc c, bp n tp th, v sinh c nhn hc sinh, bo him y t Cn thng xuyn xung im gip h v tinh thn h t lc th mi d nhn im thnh din rng. Cng c ni chn im i ngoi, vn ti khi c iu kin, im i ni nhn rng nhanh chng v im lm th theo m hnh mi m cha dt khot l hon ton c th nhn rng. Trong mi trng cng nn chn lp im ri khi lp im v y t trng hc. Mi chuyn y t cng nn c nhng im ring nh bo him y t, nha hc ng, phng chng ma tu hc ng hay phng chng HIV/AIDS.
4.8. Nhn din

Mc tiu chnh ca y t trng hc l phi nhn ra din rng cc thnh qu v y t trng hc. C ba cch nhn din: mi ti im tham quan, hc tp lm theo, tng hp cc im tt ri ph bin qua cc bi hc kinh nghim ca h. T chc kim tra cho ln nhau di s ch tr ca cp ch o gy kh th thi ua nh mun tt hn bn c im cao hn v c khen thng cui nm. Trnh t tng n thua khi t chc kim tra cho nhau.
4.9. iu tra, nghin cu v y t trng hc

iu tra, nghin cu cc ch pht trin th lc, tnh hnh bnh hc ng, tnh hnh v sinh hc ng, v sinh an ton thc phm, t l nhim HIV/AIDS, t l 136

nghin ht, tim chch ma tu, vn hc phm, trang phc hc ng, bnh rng ming, cc iu tra kin thc, thi , thc hnh v mt ch (KAP) trong hc sinh v gio vin.
4.10. S kt, tng kt

C th t chc s kt hc k, tng kt nm hc hoc nm nm mt ln, tin hnh ring tng ngnh: Y t, Gio dc v o to hay chung ca c ban y t trng hc tng cp. Sau mi ln s, tng kt phi rt ra bi hc g v phi c bin php thc y phong tro ngy thm mnh m. Lu : c khen th phi c thng, c ph th phi c pht. Mi nghip v qun l l cm nang gip cho cn b ch o lm tt cng tc y t trng hc. Mun vy phi su v chuyn mn th mi ng hng. Chng ta cn chi tit mi nghip v trn cho a phng mnh, chc chn s thnh cng. Chuyn mn v nghip v c mi tng quan hai chiu l nh vy, khng th coi nh mt no. Nhng ngi cn hc nghip v l nhng cn b lnh o y t trng hc cc cp nh tnh, huyn, x.
PHN 2. NNG CAO SC KHO TI NI LM VIC

Mt ni lm vic c NCSK s to ra mt mi trng h tr, duy tr v NCSK cho ngi lao ng. N cho php cc nh qun l v ngi lm vic tng cng bo v sc khe ca bn thn h, to iu kin cho h c ngh lc, nim tin v hi lng vi cng vic ca mnh, nh m hiu qu lao ng tng cao, lm giu cho x hi. Cc hot ng nh phng chng bnh ngh nghip v an ton lao ng c trin khai t rt lu ti ni lm vic, song k t khi c hin chng Ottawa (1986), cc hot ng nng cao sc khe (NCSK) mi c ch n. Cng vi chnh sch i mi, cng nghip ha v hin i ha t nc, ngy cng c nhiu ngi vo lao ng ti cc khu cng nghip v doanh nghip. Thc t ny t ra nhiu vn trong vic bo v sc khe ngi lao ng trong mi trng sn xut. Phn ny s tp trung tho lun mt hng tip cn mi trong vic bo v sc khe ngi lao ng thng qua cc hot ng NCSK ti ni lm vic.
2.1. Khi nim

NCSK ti ni lm vic l nhng hot ng gio dc, t chc hoc cc hot ng kinh t c thit k nhm ci thin sc khe ngi lao ng v qua ci thin sc khe ca cng ng. Nh vy NCSK ti ni lm vic khng ch l nhng hot ng y t m n bao gm nhiu hot ng khc nhau, min sao nhng hot ng ny c ch cho sc khe ca ngi lao ng. Mt ni lm vic c NCSK nhm: To ra mi trng lm vic an ton, c h tr v sc khe Pht trin nhng ni lm vic c gi tr x hi, h tr v duy tr sc khe cho lc lng lao ng v vic bo v v NCSK tr thnh mt phn quan trng ca cng tc qun l 137

 H tr s tham gia ca ngi lao ng v ngi s dng lao ng c c nhng li sng lnh mnh Li cun v m rng s tham gia ca cc thnh vin phm vi ni lm vic, gia nh v cng ng. Ni lm vic trong bi ny ng l nhng t chc nh nc (c quan, doanh nghip) v cc t chc t nhn (doanh nghip) c s dng lc lng lao ng tp trung (gi chung l t chc). Bi ny khng cp n lc lng lao ng phn tn (nng dn) mc d h l lc lng lao ng ng nht hin nay.
2.2. S cn thit phi nng cao sc kho ti ni lm vic

S thnh vng ca mi quc gia ph thuc vo kh nng ng gp ca lc lng lao ng ca quc gia , v th cn phi chm lo sc khe ca h. Vic ch n sc khe ca ngi lao ng l mt cch u t khn ngoan bng cch tng cng cc hot ng gio dc v NCSK cho nhng i tng ny. Ti iu 4 " Lut Bo v sc khe nhn dn v cc iu l p dng Lut" (1991) c qui nh r: "Cc c quan Nh nc, cc c s sn xut, kinh doanh Nh nc, cc n v v trang (gi chung l cc t chc Nh nc), cc c s sn xut, kinh doanh ca tp th v t nhn c trch nhim trc tip chm lo, bo v, tng cng sc khe ca nhng thnh vin trong c quan, n v mnh." Lut cn qui nh r trch nhim ca cc t chc Nh nc v T nhn trong vic m bo sc khe ngi lao ng, trong nhn mnh n v sinh lao ng, phng chng bnh ngh nghip v chm sc y t. Mt s c im v lc lng lao ng v hot ng NCSK: Lc lng lao ng chim khong 45% dn s trong lao ng nng nghip chim n 2/3, cn li l cc ngnh ngh khc nh cng nghip ch bin (3.207.800), xy dng (940.000), vn ti v kho bi (929.200), khai thc m (219.300)... Nhng ngi ny khng c tip cn v hng li t nhng hot ng NCSK cng ng trong gi lm vic. Mi mi trng lm vic c c th khc nhau m dch v y t chung c th khng ph hp. D tip cn h trong gi lm vic. Mi trng lm vic thng c tnh k lut cao, nn d t chc hot ng, d khuyn khch s tham gia ca nhng i tng hng li. Mi ngi hng li t nhng hot ng NCSK ti ni lm vic l mt ht nhn NCSK cho gia nh h v qua ci thin sc khe cng ng. Thng qua vic NCSK ti ni lm vic, cc thi quen, hnh vi, np sng v lm vic lnh mnh c hnh thnh gip ngi lao ng c th kim sot c cc yu t nh hng n sc khe ca h gp phn bo v, duy tr v nng cao tnh trng sc khe, cht lng cuc sng ca h. 138

2.3. Cc hot ng nng cao sc kho ti ni lm vic hin nay

Nhn chung nc ta NCSK l mt khi nim kh mi, v i vi cc t chc th khi nim ny cn kh xa l. Nhng hot ng hin nay ch yu l cc hot ng y t bao gm khm cha bnh nh k, s cp cu, v sinh an ton lao ng v phng chng bnh ngh nghip. Tng ng vi nhng nhim v ny, h thng t chc y t trong cc t chc Nh nc v t nhn thng bao gm b phn y t v mt mng li an ton v sinh vin. Tuy nhin cc t chc t nhn, c bit l cc doanh nghip nh, i khi khng tn ti h thng ny. Trong qu trnh trin khai cc hot ng ti ni lm vic, nhng kh khn thng gp c pha ngi s dng lao ng v ngi lao ng. V ngi s dng lao ng: Khng quan tm do khng nhn thc c tm quan trng v li ch ca chng trnh, c bit l i vi cc doanh nghip t nhn, doanh nghip nh khng c mng li y t. Thng cho rng Nh nc c trch nhim m bo sc khe ngi lao ng, doanh nghip c ngha v np thu, nn khng mun chi tin cho cc hot ng NCSK. Khng ng h cc hot ng v s nh hng n li nhun. Cho rng ngi lao ng phi c trch nhim t bo v sc khe ca mnh V pha ngi lao ng: Khng nhn thc c li ch thit thc ca chng trnh NCSK. Khng mun cp n quyn c tip cn dch v y t v thng tin v sc khe v s nh hng n vic lm. Khng mun tham gia cc hot ng v mt thi gian sn xut, nh hng n thu nhp, nht l hin nay a s cc doanh nghip thc hin ch khon sn phm. Trong nhng nm gn y, do dch HIV/AIDS lan rng, chng trnh phng chng AIDS ti ni lm vic c trin khai trong cc t chc v doanh nghip ln. i vi cc doanh nghip, chng trnh ny c thc hin thng qua quan h i tc gia mng li phng chng AIDS ca ngnh y t v mng li qun l ca Phng Cng nghip v Thng mi Vit nam. Nhng thnh cng ban u ca chng trnh ny cho thy, khi ngi s dng lao ng v ngi lao ng nhn thc c li ch thit thc ca chng trnh, h s sn sng u t ngun lc thc hin chng trnh.
2.4. Li ch ca chng trnh nng cao sc kho ti ni lm vic

i vi ngi s dng lao ng, mc ch ca h l to ra li nhun, nn c th h khng mun u t nhiu cho cng tc chm sc sc khe cho ngi lao ng. Tuy nhin h li c hng li rt nhiu t nhng hot ng NCSK ngi lao ng, t 139

nht vic NCSK ngi lao ng cng khng lm gim kh nng to ra li nhun ca t chc . Cc chi ph lin quan n mt lc lng lao ng khng khe mnh c th tm tt nh sau: Chi ph cho vic tuyn v o to nhn vin thay th nhng ngi phi thi vic v l do sc khe. Chi ph trc tip phi tr cho nhng ngi ngh m. Chi ph gin tip (c hi) do nhng ngi m. Chi ph do gim nng sut lao ng v mt mi. Chi ph bi thng cho nhng trng hp tai nn hoc ri ro ngh nghip. Nhng li ch ca NCSK i vi ngi s dng lao ng (hay c quan /doanh nghip) l: Gim chi ph y t v cc chi ph c hi nu trn. ng vin tinh thn lm vic v thin cm ca ngi lao ng. Tng nng sut lao ng do lc lng lao ng khe mnh hn. To ra mt hnh nh tt p v t chc v ngi s dng lao ng v bit quan tm v c trch nhim vi ngi lao ng. i vi hu ht ngi s dng lao ng, h u nhn thc c rng ngi lao ng l ti sn ln nht ca t chc, do chng ta c c hi thuyt phc h hnh ng bo v lc lng lao ng.
2.5. Cc nguyn tc c bn

Theo Hin chng Ottawa v NCSK (1986), NCSK phi nhm to ra c mt mi trng tch cc h tr cho vic ci thin sc khe thng qua vic pht trin t chc. Ba tip cn cn thit t c mc tiu ny l: Xy dng mt mi trng sng v lm vic lnh mnh cho mi ngi. Lng ghp chng trnh NCSK vo cc hot ng hng ngy mi trng . To ra nhng iu kin khuch tn nhng chng trnh ny sang mi trng khc bng cch xy dng v pht trin mng li lm vic v cc lin minh cht ch. Cc hot ng NCSK ti ni lm vic trc ht nhm gii quyt cc vn ny sinh ti ni lm vic, c bit l cc vn i hi c s thay i v chnh sch. Chng trnh NCSK ti ni lm vic cn phi thc hin thng qua s kt hp cht ch vi cc hot ng an ton lao ng v phng chng bnh ngh nghip thng qua cc quan h i tc.

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NCSK ti ni lm vic l mt chin lc tng th nhm em li li ch cho c t chc v ngi lao ng m c th l m bo v tng cng sc khe ngi lao ng v tng nng sut lao ng. Chng trnh NCSK ti ni lm vic ch c th thc hin c khi c s cam kt v hp tc gia ngi s dng lao ng, ngi lao ng v cc t chc i din cho quyn li ca ngi lao ng nhm to ra mt mi trng lao ng v x hi c tnh h tr ngi lao ng.
2.6. Chin lc nng cao sc kho ti ni lm vic

C bn chin lc quan trng nht trong NCSK ti ni lm vic: Hnh thnh s nht tr v mc ch ca chng trnh thng qua mt ng li, chnh sch r rng: da trn tn ch, mc ch, gi tr ca t chc. Mt ng li, chnh sch chung v m bo v tng cng sc khe ngi lao ng s l tin thc hin chng trnh NCSK mt cch c hiu qu thng qua s phi hp v lng ghp cc hot ng y t v x hi, trnh s lnh ph ngun lc. Xy dng t chc v cc c nhn c kh nng: thng qua vic nng cao nng lc cho t chc ( p ng tt hn nhu cu v sc khe ca ngi lao ng) v cc c nhn (nhn thc r hn v quyn v trch nhim), nhn mnh n s tng quyn cho cc t chc i din cho ngi lao ng v ngi lao ng. Loi tr nhng cng thng khng cn thit v mt t chc: to ra mt mi trng lnh mnh nht, ng vin tinh thn ngi lao ng. Cam kt v hnh ng hng ti mt mi trng t chc lnh mnh hn: tng th ca cc chin lc trn y.
2.7. Thc hin chng trnh

Ngoi nhng yu cu nh cc chng trnh NCSK ni chung, chng trnh NCSK ti ni lm vic cn c nhng c th ring. Vic thit k v thc hin mt chng trnh NCSK ti ni lm vic bao gm cc bc nh sau: Xc nh ngi xy dng v ch o chng trnh, c ch hot ng v iu phi. Xc nh cc iu kin tin quyt cho chng trnh (s cam kt, lnh o, cc ngun lc). La chn cc vn sc khe (bao gm c nh gi nhu cu). Lin h vi cc cn b y t, mng li an ton v sinh vin. Xc nh mc ch v loi chng trnh (nng cao nhn thc, thay i hnh vi, ci thin mi trng lao ng ). Lp k hoch hot ng v huy ng cc ngun lc. Theo di v nh gi chng trnh. 141

Cc yu t m bo thnh cng Cam kt mnh m ca cc cp lnh o, c bit l ca cp U ng (ni c t chc ng). Thnh lp (hoc s dng nu hnh thnh) ban iu phi /qun l chng trnh m bo s ch o thng nht, huy ng ngun lc v s tham gia ca ngi lao ng vo tt c cc giai on ca chng trnh. Chng trnh c thit k da vo kt qu ca nh gi nhu cu nhm m bo p ng nhu cu thc s ca ngi lao ng. C s phi hp vi cc hot ng y t x hi khc trong t chc, v c s phi hp vi cc hot ng NCSK cng ng. a ra nhiu chin lc nhm thay i hnh vi. To ra mt mi trng x hi v cc iu kin vt cht h tr cho chng trnh. S dng cc c s vt cht ca t chc v thc hin cc hot ng trong gi lm vic nu c th. Li ko, khuyn khch s tham gia t gic ca ngi lao ng. Vn ng s ng h v thu ht s tham gia ca cc ban ngnh, on th trong t chc. NCSK ti ni lm vic l mt cch vn dng c th ca NCSK cc mi trng khc nhau (ni lm vic, nh trng, bnh vin, cng ng). Nm c nhng nguyn tc v chin lc c bn ca nng cao sc khe ti ni lm vic s gip chng ta thit k v thc hin mt cch c hiu qu chng trnh ny.
TI LIU THAM KHO
1. Cng Ho X Hi Ch Ngha Vit Nam, (1991). Lut Bo v sc khe nhn

dn, nh xut bn Y hc.

2. Egger, G. Spark, R. & Lawson, J. (1999). Health Promotion Strategies and

Methods, The McGraw Hill Companies Inc. Sydney.

3. Kemm, J. & Close, A. (1995). Health Promotion - Theory and Practice,

Macmillian Press LTD, London.

4. Naidoo, J. and Wills, J. (2000). Health Promotion - Foundations for Practice

(2nd Ed), Harcourt Publishers Limited, London.

5. Nguyn Huy Nga (2003). Cng tc y t trong trng hc, nh xut bn Y

hc.
6. T chc Y t th gii, (1986). Hin chng Ottawa, Geneva

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