의료관리학

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1 건강행태 Health Behavior

2 UN NCD Summit 을아시나요? * NCD : Noncommunicable disease

3 UN NCD Summit 과관련한동향 2011년 9월뉴욕 UN 본부 2001년도 HIV/AIDS 이후두번째 UN 차원의보건분야 Summit 질병 : 암, 심혈관계질환, 당뇨, 만성폐쇄성폐질환 위험요인 : 식이 ( 소금섭취 ), 음주, 흡연, 고혈압, 고혈당, 과체중 / 비만, 신체활동 25 by 25 target : 2025년까지 NCD 사망률을 25% 감소 UN Post-2015 development agenda

4 행태 (behavior) 란? 특정행위를하거나또는특정행위를회피하는행위. 의식적, 무의식적인가에따른구분은없음. 한사람의건강상태는행태가아니지만, 본인의건강에대한자각 (perception) 은행태의범위에포함. 건강관련행태 (health related behavior) 란?

5 Kasl & Cobb s Definition 건강행태 Health behaviors 본인스스로는건강하다고생각하면서 (I am healthy) 질병을예방하거 나무증상시기에있는질병을찾아내기위한행위 질병행태 Illness behaviors 스스로아프다고느끼고서 (I feel sick) 사람이진단을얻고적절한치료 법을발견하기위한행위 환자역할행태 Sick role behaviors 스스로병이있다는사실을안 (I am sick) 사람이질병에서회복하기위 하여취하는행동

6 Kasl 과 Cobb 에의하면건강관련행태는크게 3 가지로나 누어볼수있다고한다. 다음은어떤행태로볼수있는가? 홍길동씨는뚱뚱해지지않기위해매일아침조깅을한다. 홍길동씨는당뇨병을앓고있기때문에혈당측정기를사서사용하고 있다. 홍길동씨는건강검진을위해보건소를찾아갔다. 홍길동씨는고혈압의진행을막기위해저염식과혈압약복용을일상 화하고있다. 홍길동씨는뒷머리가땡기는증상으로혈압을재기위해보건소를방

7 의사에게행태는왜중요한가?

8 Hypertension Rule of halves 절반의법칙 50% not diagnosed 50% diagnosed 50% not treated 50% treated 50% poorly controlled 50% well controlled 12.5% of all hypertensives

9 건강행태모형 ( 설명틀 )

10 건강관련행태모형의분류 예측모형 (prediction model) 보건의료서비스이용에영향을미치는사회인구학적, 경제학적요인을분석, 정책과제를제시하는데에초점을둔모형, 보건정책가가주로관심을갖는모형 예 : Andersen 모형, 경제학적수요모형등 과정모형 (process model) 보건의료서비스이용에영향을미치는개인의심리적, 정신적측면에초점을둔행태모형, 임상의사나보건교육자들이주로관심을갖는모형 예 : Health Belief Model, KAP 모형등

11 KAP Model 지식 - 태도 - 실천모형 Knowledge Attitude Practice Knowledge Attitude Belief Practice

12 KAP Model 에대한비판?? Knowledge Attitude Practice K A P

13 Health Belief Model (HBM) 건강신념모형 1950년대 US Public Health Service의사회심리학자들에의해개발 특정건강검진프로그램 ( 결핵 ) 에사람들이참여하지않는이유를설명하기위한목적이시초 즉, 일회성의건강검진, 예방접종과같은행태를설명하고행동변화를유도하기위한모형으로출발 보다긴기간에걸쳐형성되거나행동변화가요구되는행태 ( 예 : 흡연등 ), 질병행태, 환자역할행태등으로적용범위가넓혀짐.

14 Health Belief Model

15 다음은김씨가금연이라는건강행태를선택하게된과정에대한사례이다. 건강신념모형 (Health Belief Model) 을구성하는각요소들에대응하는문장을찾아서쓰시오. 김씨는 44 세남자로중소회사인 실업영업과장이다. 김씨는고등학교 3 학 년이었던 25 년전부터담배를피워왔다. 물론김씨는담배를끊으면여러가지 로좋다는것을몇번의금연경험을통해알고있다. 담배에들어가는돈이나 주변이깨끗해지는것은둘째치고라도우선상습적인기침과가래가줄어들었 다. 담배를계속피우면폐암에걸리기쉽고폐암에걸리면기껏해야 1 년을버 티지못하고죽는다는사실도알고있기는하다. 하지만회사일을하다보면 스트레스도많고특히술자리를갖다보면담배가저절로따라오기때문에이 래저래끊지못하고있다. 영업과장으로서주변업체사람들과어울리기위해 서는담배가필수적이되어버린것이다. 그런데최근김씨는그회사의이사로 있던상사의상가에갔다온후, 최근담배를끊어야겠다는결심을굳히고실행 에옮기기로했다. 그상사는폐암으로 55 세의나이에세상을떠났는데, 김씨는 자신도그렇게될지모른다는생각을갖게된것이다.

16 다음은김씨가혈압약복용이라는행태를선택하게된과정에대한사례이다. 건강신념모형 (Health Belief Model) 을구성하는각요소들에대응하는문장을찾아서쓰시오. 김씨는 면에사는 56세농부로 5년전부터뒷골이땡기는증상을주소로읍내의원을방문하여고혈압진단을받았다. 그후 6개월간그의원에서주는혈압강하제로치료를받아오다임의로치료를중단하였다. 물론고혈압치료를하지않으면중풍같은합병증으로고생한다는말을의사에게서들었던기억은있지만 설마나에게그런일이있을까 하는생각에다가, 당장은증상이심하지도않고매일약을먹는것도귀찮아서약먹기를중단하고있다. 그러던중지난달, 같은마을에서양계장을하던이씨가중풍으로사지의왼쪽편을쓰지못하는신세로드러눕게되었다는소식을접한후, 김씨는마음을고쳐먹고읍내의원을찾아가기로다짐을하였다. 이씨또한고혈압을앓고있었는데그동안치료를해오지않았고, 김씨는자신도이씨처럼될지도모른다는생각을갖게된것이다.

17 Theory of Reasoned Action (TRA) and Theory of Planned Behavior (TPB) 합리적행동이론과계획된행동이론 TRA : 1967 년 Fishbein 에의해개발 (Fishbein 모형이라고도불림 ) 특정문제또는질병에대한태도 (attitude toward an object) 와그문제를해결하기위한행태에대한태도 (attitude toward a behavior with respect to that object) 를구분하였음. 예 : 유방암에대한태도 vs mammography 에대한태도 또한 belief, attitude, intention, behavior를구분하여정의하고측정하려하였음. TPB : Ajzen 등에의해 TPB 요소가추가 동기 (motivation, intention) 만으로는행태가일어나지않는다. 그동기 를실현할수있는능력 (ability) 이필요하다.

18 * 그림자가있는영역은이성적행동이론, 전체그림은계획된행동이론을의미

19 The Transtheoretical Model (TTM) and Stages of Change 범이론적모형과변화단계 Psychotherapy 분야의 300 여개의이론들에있는행태변화과정에 대한이론을체계적으로통합한모형 어떤하나의이론이변화무쌍한행태변화과정을설명할수없다고생각 행태변화는일련의과정으로보고, 특정시점에서특정의프로세스에 의하여행태변화가촉진될수있다고생각 기존이론들의비교분석을통하여행태변화와관련있는 10개의프로세스를도출함. Consciousness raising Freudian tradition Contingency management Skinnerian tradition Helping relationships Rogerian tradition

20 Processes of change that mediate progression between the stages of change

21 Social Cognitive Theory 사회인지이론 Social Learning Theory 라고도불림. 행태, 개인요인, 환경요인의 3가지요소가서로상호작용한다는생각에서출발 어느하나가다른하나의원인도, 결과도될수있다고생각 ( 상호결정론 reciprocal determinism) 개인요인 개인요인, 환경요인, 행태와의상호작용을통하여행태변화의가능성을높임. 행태변화를위한개인의지식과기술향상에초점을둠. 자기효능감 / 자아효능감 (self-efficacy, Bandura, 1995) 의중요성 : 개인이특정행동을하는데있어서느끼는자신감, 점증적과정의반복적성공을통하여강화

22 Social Cognitive Theory의주요개념과정책적함의 (1)

23 Social Cognitive Theory의주요개념과정책적함의 (2)

24 건강행태모형의비판적검토 : 건강행태모형에기반한지역사회건강증진 프로그램은성공하였는가?

25 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 programes, 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.

26 North Karelia Study in Finland Puska et al, Annu Rev Public Health (1985) Vartiainen et al, BMJ (1994)

27 North Karelia Study in Finland

28 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.

29 Stanford Five-City Project, Northern California Fortmann & Varady, Am J Epidemiol (2000)

30 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.

31 Result of the COMMIT Study The COMMIT Research Group, Am J Public Health (1995)

32 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%

33 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

34 왜대부분의지역사회건강증진프로그램은대조군에비해큰개선효과를보이지못하였는가? 우리는건강행태의원인에대하여제대로파악하고있는가?

35 건강행태연구에서의주요개념과행태변화의기본적접근법 Attitudes Perceived susceptibility Benefit, barriers to action Cues to action Health motivation Health locus of control Self-efficacy Norms Motivation Prediction of Behavior

36 그러면, 건강행태를어떻게이해할것인가?

38 70 소득 5 분위에따른연령표준화흡연율차이의증가양상 년도국민건강영양조사자료분석결과 (25 세이상 ) % % I ( 저소득 ) II III IV 6 I ( 저소득 ) II III IV 45 V ( 고소득 ) 4 V ( 고소득 ) / / 남성 여성

39 Victim Blaming 피해자비난

40 건강행태를이해하기위한두가지측면 Lifecourse Context Individual Health Behaviors Multi-time point Adoption and maintenance Multi-level Extra-individual

41 WHO 의 Best Buy 정책

42 기업의자체규제, 공공-민간협력이효과가있다는과학적근거는없다. 공공규제와시장개입이야말로불건강한상품을생산하는기업 ( 담배, 주류, 식품및음료기업 ) 에의해야기되는해로움을막을유일하게근거있는정책이다.

43 건강행태의역사적맥락

44 Lalonde Report Health Field Concept 건강의장모형

45 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)

46 Lalonde Report 를보는두가지시각 건강증진 Health Promotion 활동의기초가됨. 건강에서의개인책임 individual responsibility 에대 한강조

47 건강행태의역사적맥락 1950년대이후의의학발전 1970년대 의료분야에대한지출증가 ( 영국의 NHS, 미국의 Medicare와 Medicaid) 에도불구하고, 이에따른추가적인삶의질의증가는미미한상황 1950년대의의학에대한열광이사라지고, 의학분야에대한냉소주의, 불신, 허무주의가자리잡음. 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

48 기억해둘것들 건강행태의중요성 건강관련행태의분류 - 건강행태, 질병, 환자역할행태 KAP 모형에서 K, A, P는각각무엇? 건강신념모형 - 모형의적용 범이론적이론의적용분야 금연상담 Self-efficacy 자기효능감 Victim blaming 피해자비난 Lalonde 보고서와건강의장모형

건강행태의개념과현황 Health Behaviors: Concepts and Current Status 서울의대의료관리학교실강영호

건강행태의개념과현황 Health Behaviors: Concepts and Current Status 서울의대의료관리학교실강영호 다룰내용 건강관련행태, 건강행태의개념 건강행태의중요성 : UN NCD Summit과건강행태 건강행태의설명모형 우리나라주요건강행태의현황 건강행태의개념 행태 (behavior) 란? 특정행위를하거나또는특정행위를회피하는행위. 의식적, 무의식적인가에따른구분은없음.