健康な地域づくり(ヘルス・プロモーション)の活動効果と活動方法論

WHOは、1986年に人々が健康になれる政策を幅広く捉え、公共政策としての優先性を高め、同時に位置づけを高めていくヘルス・プロモーションの必要性を示した。研究目的は、健康な地域づくり(ヘルス・プロモーション)活動の効果を量的にみた効果と質的にみた効果にわけて追跡評価し、同時に活動を推進させるための実践方法を明確にし、再現性の条件を探ることである。調査対象は、熊本県阿蘇郡蘇陽町である。分析方法として、活動経過は社会科学的な方法を用いて記述し、量的にみた活動効果は疫学的に分析し、質的にみた活動効果は、社会科学的に分析した。4年間の健康な地域づくり活動効果を健康度でみると、全死亡数のなかで、65歳以下で死亡する割合が、4年前の22.1%から18.2%にまで低下した。寝たきり者の健康志向意欲や希望では、楽しみがないとした人が、4年前の52.0%から32.9%にまで低下した。介護をかわってくれる人の割合は、4年前の20.0%から95.0%に増加した。これらのことが実践されるために必要となる施設の基盤整備として、特別養護老人ホームと介護支援センターそれに訪問看護ステーションがそれぞれ1施設整備された。一方マンパワーでは、ホームヘルパーが5人に、保健婦は1名増員され2名になった。最も重要な質的にみた活動効果は、見学をしていただいた方々に対して、健康推進委員である健康村長(むらちょう)が、自分達のこれまでの活動の取り組みを自信を持っていきいきと説明している姿そのものである。ちなみに町外から視察に訪れた団体は、現在までに900団体以上にのぼった。健康なまちづくり活動を推進させるための最も大切な要因は、町の健康計画策定プロセスにおいて、住民がアイデイアを提供していく存在として位置づけられたことであった。また、活動計画の対象分野は、従来の保健医療福祉に限定せず、清流確保を含めた自然環境を整備することや、無農薬野菜づくりをすすめる農業振興策、子供の歯科保健を中心とした学校健康教育を推進させることが活動方針に組み込まれていったこと、さらには車椅子でも宿泊できるキャンプ場建設などの余暇開発も視野に入っていたことである。これらのことが、WHOが提起するヘルスプロモーションの指針に合致していた。活動の特性ないし推進要件としては、活動を推進するリーダーが首長や医師主導型ではなく、住民が主体となり、そこに生活する住民の健康レベルアップが最も重視され、活動目標の設定や達成方法の選定や実践活動では、住民と職員が中核になって、各団体各機関の協力を得て組織的にすすめられたこと、さらに活動効果を数量的、質的に評価して関連情報を公開していったことがあげられた。今後の課題として、他の地域での比較研究を進めて再現性を確認することや、保健所や研究機関が健康事業を評価しシステムを改善させる支援活動を続ける必要性が考察された。

On the basis of the new Health Service Act, municipalities have responsibility to enforce health services available to every person soon after 1997. The purpose of this study is to examine the fundamental factors surrounding the development of Health Promotion Program in the municipality, by reviewing the four years achievements and implementational effects regarding a health services for the elderly persons in Soyo town of Kumamoto Prefecture. In order to determine both the effectiveness and the promoting factors of Health Promotion programs for elderly person in Soyo town, the pre-survey and post-survey have conducted, and concerned researches are systematically reviewed. The main programs of Health Promotion were as follows: 1) For enforcing the Health Promotion program for every person, we pointed out that it is most important to set up the personnel health system and medical facilities in Soyo town. 2) Soyo town has put emphasis on the development of the comprehensive health care system corresponding to the needs of the elderly persons. 3) Each and every sector of local goverments is responsible for monitoring the consequences of his own health policies and drawing up suitable health policy objectives. However, a real purpose is to improve health for all people in town rather than just promoting the implementation program itself. 4) For the purpose of developing a joint program of co-operation, Health Centers and Soyo town itself have come to a general agreement concerning collaboration especially in terms of consultancy work referrals training and development activities as well as regional health care implementation programs. The main effects of Health Promotion programs were as follows; 1) The main effectiveness of Health Promotion programs especially for the elderly person in Soyo town, can be divided into two points, one was a quantitative effect and the other was a qualitative one. 2) The main quantitative effects was decreasing the pre-mature death rate, from 22.1% in 1988 to 18.2% in 1992, and also the rate of QOL of elderly persons was also increasing 48.0% in 1988 to 67.1 % in 1992. 3) On the other hands qualitative effects were to increasing the status of the health section among the other sectors of local goverment. 4) The involvement of the health services in municipal basic planning has been designed so that both democratic influence and health planning can be strengthened. Several comments pointed out that promotional effects of Health Promotion programs were as follows: 1) Future research should emphasize the assessment of Health Promotional interventions, because health level in Soyo town was not high enough and actual health practices should be compared to their availability as within other municipalities of Japan. 2) This study suggested that it was important to make clear not only the effectiveness of Soyo town itself but also the effect of other town for the comparative research in near future. 3) As for the construction plans for health service centers, it is desirable to construct them on sites nearest to the city halls so that many of the staffs of the municipal office can follow up on their health related activities. 4) Since an advisable health care plan on equal terms for the entire population can be achieved in a more satisfactory manner than the present one, the Ministry of Health and Welfare is transferring various kinds of authorities to the municipalities. From now on, the Ministry of Health and Welfare should extend financial aid to both Health Centers and municipalities. 5) In developing people-oriented health technologies, priority should be given to available lay resources and to indigenously developed health practices. 6) People should also be given greater opportunity to participate actively in the design of health care services and the process of their planning system. 7) It is desirable that the Health Center should perform the evaluation of the health care systems with the municipality simultaneously. It is very important for people to participate in their own health planning process from the view point of health promotion.