지역사회 프로그램의 효과성

- 우리는 효과가 있는 프로그램을 지역사회에 적

용하고 있는가?

Lifestyle, CVD risk factor, Risk Factor Epidemiology,

and Their Historical Backgrounds

“In the 1970s and 1980s large scale intervention studies were set

up, designed to assess whether specific intervention programmes

could persuade (mainly) middle-aged men to change their health-

related behaviours. Research findings have generally shown rather

disappointing results, both of risk factor change and subsequent

reductions in mortality and morbidity.”

Schooling & Kuh, 2002

North Karelia Study in Finland

• The most prominent community-based experiments. (Ebrahim & Davey Smith, Eur Heart J 1998)

• Support of local community leaders and the general public.

• Involved mass media, workplaces, primary care, hospitals, schools and local communities.

• Provided training programmes, mobilization of public support through local leaders, formation of new social organizations such as housewives groups, and targeting of grocery shops and the food industry.

North Karelia Study in Finland

Puska et al, Annu Rev Public Health (1985)Vartiainen et al, BMJ (1994)

North Karelia Study in Finland

Three Major Community-Based Cardiovascular Disease Intervention Trial in the US, Funded by NHLBI

• Stanford Five-City Project, funded in 1978

• Minnesota Heart Health Program, funded in 1980

• Pawtucket Heart Health Program, funded in 1980

Stanford Five-City Project, Northern California

• 6-year multifactor risk reduction education program that was coordinated, comprehensive, and community-wide.

• Had multiple target audiences and used multiple communication channels and settings (including newspapers, television and radio, mass-distributed print media, classes, contests, and correspondence courses)

• Change in diet, regular BP checks, reduced salt intake, reduced weight, increased exercise, and full adherence to antihypertensive medication regimens.

• On average, each adult in the two treatment cities was exposed to about 5 hours per year of Five-City Project educational messages.

Stanford Five-City Project, Northern California

Fortmann & Varady, Am J Epidemiol (2000)

Results of Stanford Five-City Project, Northern California

Fortmann & Varady, Am J Epidemiol (2000)

Over the full 14 years of the study, the combined-event rate declined about 3% per year in all five cities. However, during the first-7 year period (1979-1985), no significant trends were found in any of the cities; during the late period (1986-1992), significant downward trends were found in all except one city. The change in trends between periods was slightly but not significantly greater in the treatment cities. It is most likely that some influence affecting all cities, not the intervention, accounted for the observed change.

“In recent years, we have seen a number of well-conducted, large-scale trials

involving entire communities and enormous effort. These trials have tested the

capacity of public health interventions to change various forms of behavior, most

often to ward off risks of cardiovascular disease. Although a few had a degree of

success, several have ended in disappointment. Generally, the size of effects has

been meager in relation to the effort expended. That was the case with one of the

first such trials, the ambitious Multiple Risk Factor Intervention Trial (MRFIT).

It is also the case with some recent trials, for instance, the Stanford Five-City

Project, the Minnesota Heart Health Program, and now the 26-worksite Take

Heart trial and the 22-city COMMIT trials, which have smoking-related cancers

as the ultimate target.”

Mervyn Susser, Am J Public Health 1995

개별 위험요인에 초점을 둔

지역사회 행태 변화 프로그램은 성공하였는

가?

The COMMIT Study

• Community Intervention Trial for Smoking Cessation Study

• One of the best planned randomized controlled trials at the community level

in health promotion. (Ebrahim & Davey Smith, IJE 2001)

• Model of meticulous design, focused intervention, and careful analysis.

(Susser, AJPH 1995)

• 11 community pairs, one community in each pair being randomized to

receive smoking cessation activities.

• Public education through the media and communitywide events; health are

providers; work-sites and other organizations; and cessation resources.

• Over 10 million dollars were spent on the activities.

The COMMIT

Study

Result of the COMMIT Study

The COMMIT Research Group, Am J Public Health (1995)

Result of the COMMIT Study

• Quit rate among heavy smokers: 18.7% (11 intervention villages) vs

18.0% (11 comparison villages) [0.7% difference, 95% CI=-3%,

+2%]

The cost-effectiveness was around 50,000 per heavy smoker.

• Quit rate among light-moderate smokers: 30.6% vs. 27.5%

In recent years, we have seen a number of well-conducted, large-scale trials

involving entire communities and enormous effort. These trials have tested

the capacity of public health interventions to change various forms of

behavior, most often to ward off risks of cardiovascular disease. Although a

few had a degree of success, several have ended in disappointment.

Generally, the size of effects has been meager in relation to the effort

expended. That was the case with one of the first such trials, the ambitious

Multiple Risk Factor Intervention Trial (MRFIT). It is also the case with

some recent trials, for instance, the Stanford Five-City Project, the Minnesota

Heart Health Program, and now the 26-worksite Take Heart trial and the 22-

city COMMIT trials, which have smoking-related cancers as the ultimate

target.

Mervyn Susser, Am J Public Health 1995

Review of RCT of Multiple Risk Factor Intervention (Ebrahim & Davey Smith, BMJ 1997)

StudyNo. of

participationDuration of follow up

All-cause mortality (OR, 95% CI)

CHD mortality (OR, 95% CI)

1 WHO factory study 30 489/26 971 6 0.99 (0.91-1.07) 0.95 (0.83-1.09)

2 Gotheburg study 10 004/20 018 11.8 0.98 (0.91-1.05) 1.00 (0.89-1.12)

3 Oslo study 604/629 5 0.69 (0.36-1.32) 0.44 (0.17-1.15)

4Multiple risk factor intervention trial

6428/6438 7 1.02 (0.86-1.22) 0.93 (0.72-1.20)

5 Finnish businessmen study 612/610 5 2.36 (0.90-6.17) 4.01 (0.45-35.95)

6Hypertension detection and follow up programme

5485/5455 5 0.82 (0.71-0.95) 0.88 (0.69-1.11)

7Johns Hopkins hypertension study

350/50 5 0.39 (0.18-0.84) 0.37 (0.16-0.88)

8Cost effectiveness of lipid lowering study

339/320 1.5 1.89 (0.20-21.0) 1.89 (0.20-21.0)

9 Oxcheck study 8307/2783 4 1.22 (0.86-1.74) 1.33 (0.73-2.46)

All study 0.97 (0.92-1.02) 0.96 (0.89-1.04)

All study without 6, 7 study 0.99 (0.94-1.04) 0.98 (0.90-1.06)

“In many countries, there is enthusiasm for ’healthy heart programmes’that use counselling and educational methods to encourage people to reduce their risks for developing heart disease. These risk factors include high cholesterol, excessive salt intake, high blood pressure, excess weight, a high-fat diet, smoking, diabetes and a sedentary lifestyle. … The findings are from 55 trials of between six months and 12 years duration conducted in several countries over the course of four decades. The median duration of follow up was 12 months with a range of six months to 12 years). Multiple risk factor intervention does result in small reductions in risk factors including blood pressure, cholesterol and smoking. Contrary to expectations, multiple risk factor interventions had little or no impact on the risk of coronary heart disease mortality or morbidity. … The methods of attempting behaviour change in the general population are limited and do not appear to be effective. Different approaches to behaviour change are needed and should be tested empirically before being widely promoted, particularly in developing countries where cardiovascular disease rates are rising.”

Ebrahim S, Taylor F, Ward K, Beswick A, Burke M, Davey Smith G. Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD001561.

Authors’ conclusions

“Interventions using counselling and education aimed at behaviour change

do not reduce total or CHD mortality or clinical events in general

populations but may be effective in reducing mortality in high-risk

hypertensive and diabetic populations. Risk factor declines were modest

but owing to marked unexplained heterogeneity between trials, the pooled

estimates are of dubious validity. Evidence suggests that health promotion

interventions have limited use in general populations.”

Ebrahim S, Taylor F, Ward K, Beswick A, Burke M, Davey Smith G. Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD001561.

왜 대부분의 지역사회 건강증진 프로그램은

성공하지 못하였는가?

Major Constructs in Health Psychology and Behavioral Health

• Attitudes• Perceived susceptibility• Benefit, barriers to action• Cues to action• Health motivation• Health locus of control• Self-efficacy• Norms

Motivation

Prediction of Behavior

건강행태를 어떻게 이해할 것인가?

건강증진 프로그램을 어떻게 개발하여야 할 것인

가?

The difficulty encountered in changing health damaging behaviours in adult life

gave rise to three development. The first was to stimulate research into the

childhood and adolescence origins of these behaviours so that strategies to

prevent the initiation of unhealthy lifestyles could be developed. The second

was a growing recognition that the sociocultural context that shapes the

initiation and maintenance of health behaviours needs to be addressed by health

promotion interventions. The third was to draw attention to the long-term

trends in health behaviours and to ask what drove these changes.

Schooling & Kuh, 2002

“Current orthodoxy states that coronary heart disease results from the

unhealthy lifestyles of westernized adults together with a contribution

from genetic inheritance. Such a view, however, leaves its changing

incidence and geography largely unexplained, and offers little insight

into why one person develops the disease while another does not. The

effectiveness of preventative measures based on this view of the disease

has been questioned.”

Barker DJP. The origins of the developmental origins theory. J Intern Med 2007

Lifecourse Context

건강행태를 이해하기 위한 두 가지 측면

Individual Health BehaviorsMulti-time point

Adoption and maintenanceMulti-level

Extra-individual

0

1

2

3

4

5

6

7

Male Female

Relationship between Educational Attainment and Mortality from Lung Cancer, Transport Accidents, and All-causes in Korea

Khang et al, Int J Epidemiol 2004

Rat

e R

atio

Lung cancer

Transport accidents

All-causes

Lung cancer

Transport accidents

All-causes

언제부터 우리는 건강증진, 건강행태에

집중해 왔는가?

Lalonde Report (1974)

Health Field Concept by Lalonde

In the early seventies (what else is new!), two major concerns were growing

in Canadian government circles: (1) the rising cost of health care, and (2) the

fact that the health status of Canadians did not seem to improve

proportionately with the rise in the cost of health services. After the

significant improvements in health statistics following the introduction in

Canada of public hospital and medical insurance in the fifties and sixties, the

correlation between health expenditures and health improvement was

becoming far less direct. When I was appointed Minister of Health and

Welfare in 1972, it was clear that the issue had to be addressed.

Lalonde M, Pan Am J Public Health (2002)

Lalonde Report를 보는 두 가지 시각

• 건강증진 Health Promotion 활동의 기초가 됨.

• 건강에서의 개인 책임 individual responsibility 에 대한 강조

Behavior and Ideology: Historical Review

• 1950년대 이후의 의학 발전

• 1970년대

– 의료 분야에 대한 지출 증가(영국의 NHS, 미국의 Medicare와 Medicaid)에

도 불구하고, 이에 따른 추가적인 삶의 질의 증가는 미미한 상황

– 1950년대의 의학에 대한 열광이 사라지고, 의학 분야에 대한 냉소주의, 불

신, 허무주의가 자리잡음.

• Effectiveness and Efficiency: Random Reflections on Health Services (1972) by

Archibald Cochrane

• Medical nemesis in Lancet (1974) Medical Nemesis: The Expropriation of Health

(1976) by Ivan Illich

• The Modern Rise of Population (1976), The Role of Medicine: Dream, Mirage, or

Nemesis? (1976) by Thomas McKeown

– A New Perspective on the Health of Canadians (1974) by Lalonde

WHO 의 “Best Buy” 정책

우리나라의 NCD 정책의 현실(1)

• 정책 내용(content)의 문제

– 적극적 가격 규제정책

– 적극적인 판매 및 광고 규제 정책

– 담배/술/식품 산업에 대한 적극적 개입

– 고위험집단 접근법에 대한 과도한 의존

• 정책 참여자(power)와 정책 과정의 문제

– 정부의 정책의지

– NCD control tower의 부재

– 허약한 시민사회

– 허약한 연구집단

우리나라의 NCD 정책의 현실(2)

• 담배규제

– 담뱃값 인상, 실외금연 정책 >> 실내금연 정책, 금연클리닉, 포장 규제

(Plain packaging), 금연 광고/판촉 규제, 성분 공개 및 규제

• 알코올 규제

– 주류 가격 인상, 주류 광고 규제, 판매 규제

• 나트륨저감화 정책

– 요식업체 자율규제, 홍보/캠페인

– 산업규제

기업의 자체규제, 공공-민간 협력이 효과가 있다는 과학적 근거

는 없다. 공공 규제와 시장 개입이야말로 불건강한 상품을 생산

하는 기업(담배, 주류, 식품 및 음료 기업)에 의해 야기되는 해로

움을 막을 유일하게 근거 있는 정책이다.