건강-질병 현상에 있어서 사회경제적 요인의 중요성

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2 What is Health Behavior? A working definition by Gochman (1981, 1982, 1988) those personal attributes such as beliefs, expectations, motives, values, perceptions, and other cognitive elements; personality characteristics, including affective and emotional states and traits; and overt behavior patterns, actions and habits that relate to health maintenance, to health restoration and to health improvement. ( ),., (perception).

3 Kasl & Cobb s Definition Health behaviors (I am healthy) Illness behaviors (I feel sick) Sick role behaviors (I am sick)

4 Kasl Cobb 3.?

6 ?????.,,,

7 Hypertension Rule of halves (Beevers & Macgregor, 1987) 50% not diagnosed 50% diagnosed 50% not treated 50% treated 50% poorly controlled 50% well controlled 12.5% of all hypertensives

8 Awareness, Treatment, and Control of Hypertension based on WHO Criteria (160/95mmHg) in Korea Hypertension 42% not diagnosed 58% diagnosed 51% treated 49% not treated Anti-HT medicated 50%, SBP 160 or DBP 95 50%, SBP<160 & DBP<90

9 : Alameda 7. Regular physical activity. Low alcohol consumption. Never smoking. Not snacking between meals. Not skipping breakfast. Average weight status 7-8. sleeping seven to eight hours/night

10 Age-adjusted cause-specific mortality rates by health practice index: males aged 30-69, Alameda county, Low Medium High Ischemic heart disease Other circulatory disease Cancer All other Total

11 Age-adjusted cause-specific mortality rates by health practice index: females aged 30-69, Alameda county, Low Medium High 5 0 Ischemic heart disease Other circulatory disease Cancer All other Total

13 6-7

18 Health Risks of Cigarette Smoking Smoking Kills: A White Paper on Tobacco. UK (1998)

20 Relation between Smoking and Smoking Related Death

21 20 (2001)

22 Comparison of Smoking Rates among Males % and Females Aged 15+ by Countries Male Female Korea, 1998 Japan, 1996 US, 1998 UK, 1996 Germany, 1995 France, 1992 Singapore, 1998

23 International Comparison of Smoking Rates in Adolescents, High School 3 rd Grade Students % Male Female Korea, 1997 Japan, 1991 US, 1997 UK, 1994 Russia, 1994 Israel, 1994

24 , WHO (1990),,,,,,,,,,,,,,,,,,,,,,,,,,,, / /,,,,,,,,,,,,,,

25 , Economic Turmoil, Alcohol Intake, and Health

26 US and Russian Life Expectancy: Notzon et al., JAMA 1998

27 Proportional Changes in Age-specific Mortality in Russia Shkolnikov et al., Lancet 2001

28 Female CVD Mortality in Russia Start and end of Gorbachev anti-alcohol campaign Rate per 100K 550 Cardiovascular Collapse of USSR 350 Cerebrovascular

29 Male CVD Mortality in Russia Start and end of Gorbachev anti-alcohol campaign Rate per 100K 1250 Cardiovascular Collapse of USSR 750 Cerebrovascular

30 ., (, )? (pathophysiology)? 1. Development of atheroma - atherosclerosis 2. Thromboembolic events - rupture of unstable plaque 3. Arrythmias - disturbances to electrical conduction?

31 Beer Binging and Mortality - Finland (KIHD Project) Relative Hazard < 3 bottles (Reference) 3-5 bottles per session 6+ bottles per session* All-cause CVD External AMI Fatal AMI * Adjusted for average consumption Kauhanen et al. BMJ (1997)

32 Alcohol Consumption Behaviors in Korean Males and Females Aged 20+ in 1998 % Male Frequent Often Rarely Female

33 Age-, Sex-specific Rates of Binge Drinking (6 drinks) in One Session among Korean, 1998 % Males Females

34 KAP Health Belief Model Suchman Andersen

35 (prediction model),. : Andersen, (process model),. : Health Belief Model, KAP

36 KAP Model Knowledge Attitude Practice Knowledge Attitude Belief Practice

37 KAP Model?? Knowledge Attitude Practice K A P

38 Health Belief Model (HBM) 1950 US Public Health Service ( ),, ( : ),,.

39 HBM

40 Health Belief Model

41 Perceived barriers HBM The most powerful predictor of HBM dimensions across all studies and behaviors Perceived susceptibility A stronger predictor of preventive health behavior than sick-role behavior. Perceived benefits A stronger predictor of sick-role behavior than preventive health behavior. Perceived severity The least powerful predictor. But this dimension was strongly related to sick-role behavior. Janz, Champion, Strecher, 2002

42 . (Health Belief Model) ,. 55,.

43 . (Health Belief Model) ,.,,.,.

44 Suchman

45 ( ) 50 ( ),.. ( ).? 1. ( ) Suchman I. 2. Suchman ( ). 3. Suchman ( ).

46 ** %% 61 P (A),. (B).,... P (B)? P. Suchman. lay referral.? P.,,. [ ]... (C),. Suchman III

47 ,..? 1) (healer shopping) 2) (dependent patient role) 3) (lay referral) 4) (symptom experience) 5) (recovery)

48 Andersen

49 Andersen (propensity) :,, :,,,, (belief) :, / :,, :,,

50 (perceived needs) Need (disability days),,,, felt needs, individually defined needs (evaluated needs) medically defined needs, professionally defined needs Unmet needs,

51 E B A F C D Medically defined need Effective demand G Perceived need = Want

52 Andersen,? ,, ) (enabling factor) 2) (demographic factor) 3) (felt need) 4) (medically defined need) 5) (health belief)

53 .,.( : ) (income), (taste, preference). D = f ( I, Pn, P1,..., Pn-1, T)

54 , Law of Demand,. : : = (%)/ (%) E = 0 (perfectly inelastic) E < 1 (inelastic) : E = 1 (unitary elastic) E > 1 (elastic) :, E = (perfectly elastic)

55 (superior good) vs. (inferior good), (complementary good) vs. (substitute good) : ( : X- ) : ( : ) (public goods) vs. (private goods) Nonrivalry in consumption, Nonexclusion,

56 , Taste,,. (need).,,,,.. (supplier induced demand).. Roemer's law: A built bed is a filled bed.

57 , Physician Induced Demand Price S1 S2 D1 D2 Volume

58 E B A F C D Medically defined need Effective demand G Perceived need = Want physician induced demand?

59 ... 3, (carrier)., (need)? - - -

61 Lalonde Report (1974)

62 Health Field Concept by Lalonde

63 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)

64 Lalonde Report Health Promotion. individual responsibility Victim Blaming

65 Behavior and Ideology: Historical Review ( NHS, Medicare Medicaid), 1950,,,. 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

66 ?

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

68 North Karelia Study in Finland

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

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

71 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

72 We have learned that communities are heterogeneous and have differential responses to interventions. Perhaps communities in most need of appropriate targeting are those that include individuals from lower socioeconomic groups, who have disproportionate levels of smoking, hypertension, high cholesterol, and obesity. Despite the multiple cardiovascular disease activities during the 1980s, the disparity in risk factors and mortality between the upper and lower socioeconomic status groups increased. This continuing disparity was documented by the Five- City Project, the Minnesota program, and the Pawtucket Heart Health Program. Winkleby, Am J Public Health (1994)

73 ?? The difficulty of changing adult behaviours has led to a growing interest in the origins and development of individual behaviours and healthy lifestyles. (Schooling & Kuh, 2002)

74 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

75 Meanings of Socioeconomic Variables: Viewpoint of Health Education A variety of socioedemographic characteristics such as gender, age, race, marital status, place of residence, and employment characterize health education audiences. These factors, while generally not modifiable within the bounds of health education programs, are useful in guiding the tailoring of strategies and educational materials and identifying channels through which to reach consumers. Glanz, Rimer, Lewis. Health Behavior and Health Education: Theory, Research and Practice (3 rd Edition) p.14.

76 Preventive Health Service Use in Korean Males and Females Aged 20+ by Cancer Site and Household Income Level % or less Stomach Colon Stomach Colon Breast Ut. Cervix Males Females

77 The ideal intervention would require amelioration of the SES differential, to eliminate differences in exposure to harmful and beneficial events. However, given that this is not a feasible solution, intervention efforts might be directed toward the reserve capacity we believe moderates the relationship between threatening stimuli and negative emotional states. In particular, lower SES children might benefit from interventions designed to increase skills or sense of efficacy for coping with negative events. Gallo & Mathews (1999)

78 : Warner (1960) The lives of many are destroyed because they do not understand the workings of social class. It is the hope of the authors that this book will provide a corrective instrument which will permit men and women better to evaluate their social situations and thereby better adapt themselves to social reality and fit their dreams and aspirations to what is possible. Warner. Social Class in America. New York: Harper and Rowe, 1960, p.5

79 ,?

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

82 Childhood and Adult Socioeconomic Positions and Their Effect on Current Smoking Habits in Korea Labor and Income Panel Study (Odds ratios and their 95%CI) 2922 Males aged females Father's socioeconomic status 1.26 ( ) 1.24 ( ) 0.94 ( ) 0.86 ( ) Equivalized houshold income 1.20 ( ) 1.18 ( ) 1.90 ( ) 1.93 ( ) Khang, 2004

84 . (2002)

85 Distribution of Powerelites (Area-based Socioeconomic Indicator) and Their Effects on Current Smoking among 26,022 Males in 522 Dongs of Seoul City (Odds ratios and 95% CI) Age adjusted Age, income adjusted Age, income, education, occupational class adjusted LQ level 1 (highest) LQ level ( ) 1.14 ( ) 1.09 ( ) LQ level ( ) 1.23 ( ) 1.16 ( ) LQ level ( ) 1.24 ( ) 1.15 ( ) LQ level 5 (lowest) 1.46 ( ) 1.36 ( ) 1.25 ( ) Khang, 2004

86 (fiscal or non-fiscal)??

Trends in Male Smoking by Education, USA (1974-95) 50 45 40 35 30 25

87 Trends in Male Smoking by Education, USA ( ) < 12 years (NCHS, 1995)

88 Smoking Prevalence among UK men 16 years older, by Social Class, Lawlor et al, Am J Public Health

89 Age-standardized all-cause mortality, men from England and Wales aged years, by social class, Lawlor et al, Am J Public Health

90 SMR for Lung Cancer and Accidents by Social Class in UK Men aged 20-64, Lawlor et al, Am J Public Health (2003)

91 The current emphasis on the addictive nature of nicotine has pushed policy away from tackling root causes of disadvantage toward adopting an easier, but clearly less effective, medical model involving such strategies as stop smoking clinics and nicotine substitutes. Smoking prevalence declined among the most advantaged members of society after several decades of greater general health demonstrated by marked and consistent declines in overall mortality and improved material circumstances. To be effective, smoking cessation programs appear to depend on a perceptibly rising tide of general good health among the target population. Efforts to reduce smoking among the most deprived members of society are unlikely to succeed unless they are supported by measures designed to improve the material circumstances of these individuals. Lawlor et al, Am J Public Health (2003)

92 Age-adjusted Smoking Rates by Educational Attainment among South Korean Men aged 25-44, Social Statistics Survey, RII=1.81 ( ) RII=2.30 ( ) RII=2.77 ( ) RII=2.94 ( ) RII=3.36 ( ) 40 Middle- High College Khang, 2004

93 Age-adjusted Smoking Rates by Educational Attainment among South Korean Men aged 25-44, Social Statistics Survey, RII=0.83 ( ) RII=1.83 ( ) RII=1.81 ( ) RII=2.61 ( ) RII=6.12 ( ) Middle- High College Khang, 2004

94 Educational Differences in Smoking Initiation among South Korean Men aged 20-24, Social Statistics Survey, RII=2.28 ( ) RII=3.75 ( ) RII=5.15 ( ) RII=5.57 ( ) RII=8.34 ( ) Middle- High College Khang, 2004

95 Educational Differences in Smoking Initiation among South Korean Women aged 20-24, Social Statistics Survey, RII=4.49 ( ) RII=8.31 ( ) RII=12.0 ( ) RII=11.6 ( ) RII=36.6 ( ) 8 6 Middle- High College Khang, 2004

서론 34 2

서론 34 2 34 2 Journal of the Korean Society of Health Information and Health Statistics Volume 34, Number 2, 2009, pp. 165 176 165 진은희 A Study on Health related Action Rates of Dietary Guidelines and Pattern of