The Health Promotion Effect of Public Health Care Post User:
Focusing on Hypertension and Diabetes Control Rate
Sangjin Lee1, Eunshil Yim*2, Ahrin Kim3, KyoungA Lee4
1Director, Division of Health Policy, Ministry of Health and Welfare, 13, Doum 4-ro, Sejong-si, 30113, Republic of Korea
2Assistant Professor, Department of Nursing, Daegu Health College, 15 Yeongsong-ro, Buk-gu Daegu, 41453, Republic of Korea
3Assistant Professor, Department of Nursing, Cheongju University, 298, Daeseong-ro, Cheongwon-gu, Cheongju-si, Chungcheongbuk-do, 28503,
Republic of Korea
4Assistant Professor, Department of Nursing, Daegu Health College, 15 Yeongsong-ro, Buk-gu Daegu, 41453, Republic of Korea
*Corresponding Author E-mail: sjlee0709@korea.kr, yim7604@dhc.ac.kr, arkim@cju.ac.kr, poiuy@dhc.ac.kr
ABSTRACT:
Background/Objectives: The purpose of this study is to develop health promotion performance indicators and analyze the health promotion effects of public health care posts. Methods/Statistical analysis: A number of previous studies and existing health care assessment indicators were used to develop health promotion indexes for public health care posts. The health promotion effects were classified and analyzed according to the developed evaluation indicators. The effect of pre-and post-health promotion program were analyzed using blood pressure and blood glucose level. Findings: The health promotion performance indicators of public health care posts are classified into structure, process, and result. In particular, the indicators of health promotion results are suggested as health life practice, chronic disease management, infectious disease management and population health management. The health promotion effect was analyzed according to these indicators; smoking, drinking, exercise, obesity, oral health, hypertension, diabetes, cholesterol, depression, cancer, vaccination, dementia management, and elderly activity limit reduction. Blood pressure and blood sugar data were analyzed to measure the before and after effect of using the public health care posts. The blood pressure and glucose control rate for public health care post users are higher than the results of Korea National Health and Nutrition Examination Survey. The severity of hypertension was also lower than the severity data reported in the National Health Insurance. The high control rate of hypertension and diabetes suggest that public health care posts perform health promotion programs efficiently for residents in medical vulnerable areas. Improvements/Applications: In order to measure more valid and reliable effects, it is necessary to manage and measure the health promotion evaluation indicators presented in this study.
1. INTRODUCTION:
Public health care posts were institutionalized to perform primary medical services in medical vulnerable areas of Korea. In the 1980s, there were a lot of medical vulnerable areas, but it has been reduced by the development of transportation and healthcare systems. The government tried to reduce the number of public health care posts but encountered severe opposition of local resident. There were several problems such as the increase in expenditure on health care, the inconvenience of residents in health maintenance, and the reduced opportunity to participate in health promotion education1. In other words, the role of public health care posts changed as the health care environment changed. Public health care posts have played a major role not only in primary care but also in promoting the health of local residents. Functional changes are required to enable public health care posts to play a pivotal role in the improvement of local health with the enactment of the Community Health Act in 1995. Demand for health promotion services increased due to changes in lifestyle, population structure and disease structure. In other words, the role has changed from acute infectious disease management and prevention-centered health center function into health promotion, chronic degenerative disease management, and health care planning. In addition, Korea has enacted the National Health Promotion Act of 1995 in order to proactively cope with the health care environment and to improve the health of the people and prolong the health life. Under the law, health promotion programs include health education and health counseling, nutrition management, management of oral health, examination and prescription for early detection of diseases, research on health problems in the community, and operation of health class. In 1998, the health promotion pilot project was centered on disease management projects such as prevention of hypertension, prevention of stroke, school health, and oral health. Since the second half of 1999, activities such as smoking cessation, exercise and nutrition have been partly supplemented. Since 2002, four health behavior projects (smoking cessation, drinking, exercise and nutrition) have been implemented. Other health promotion programs include cancer management and chronic disease management such as hypertension, diabetes, arthritis, cardiovascular disease management, mental health, and oral health. Since 2013, the various programs that local governments have been carrying out are integrated as one health promotion project, eliminating redundancy and operational difficulties. As the role of public health care organizations has changed, health promotion services have been added with new health service programs of public health care posts. The activities of the early public health care posts were mainly care and prevention such as medical care, maternal health, family planning, infant and child health care, school health care, and home visit. There was a suggestion that additional health promotion and management functions were needed2. In the 1980s, maternal health, family planning, tuberculosis control, and immunization were the main tasks of public health care posts. In 2003, program contents were revised and changed into health promotion management, primary care, maternal and child health, tuberculosis management and visit management. Telephone counseling was added in the field of health promotion management in 2012. Current service areas of public health care posts are: primary medical care, health promotion, chronic diseases management, and dementia management. In other words, medical services at public health care posts are gradually decreasing but the health promotion work is emphasized. The role of community health worker not only in Korea but also around the world, is changing to provide health promotion services and organize health services. The programs provided by community health workers have varied, including cardiovascular disease, diabetes, asthma, maternal health, cancer screening and general health promotion3. Therefore, this study was conducted to develop the health promotion performance indicators as the result of the health promotion services on public health care posts and assess how much it contributed to the health promotion of the users.
2. MATERIALS AND METHODS:
2.1. Development of health promotion indicator:
In order to develop indicators for the health promotion effects of public health care posts, the evaluation framework is based on the logical model for evaluating the achievement of the key tasks of the Comprehensive National Health Promotion Plan and the Donabedian structure, process, and result model. The health promotion effects evaluation indicator considered the following indicators; health index among the evaluation areas of local governments, chronic disease management project evaluation index of International Organization for Standardization, evaluation index derived from health promotion business evaluation research, and key indicators of the National Health Promotion Comprehensive Plan. Especially, the effect indicator was selected considering the main task indicators of cardiovascular diseases. Finally, based on the above-mentioned various evaluation indexes, the indicator is selected based on data of the health clinic administration data currently used in the public health care posts.
2. 2. Analysis on Health Promotion Effect:
To analyze the health promotion effects, this study analyzed a report on the operational status of total 1,904 public health care posts in Korea released in 2014. After, the overall results of health promotion programs at public health care post were analyzed, and the results of the prevention and management of cardiac and cerebrovascular disease were analyzed. The prevention and management of cardiac and cerebrovascular diseases includes hypertension management, diabetes management, hyperlipidemia management, and obesity management. Blood pressure, blood sugar, cholesterol, and obesity levels were analyzed, but only blood pressure and blood glucose levels were used in this study. Cholesterol and obesity were inadequate for analysis because of many missing data. The blood pressure and blood glucose data of public health care post users at the first and the last visit of 2014 were analyzed and compared with the results of the 2013 National Health and Nutrition Examination Survey. The data analyzed in this study was blood pressure and blood glucose data of 24,441 people using public health care posts in 2014. The control rate of hypertension means the percentage of the total hypertensive subjects whose blood pressure is below 140/90mmHg, and the diabetes control rate means the percentage of the total diabetic subjects whose postprandial blood glucose is below 90-180mmg/dl.
3. RESULTS AND DISCUSSION:
3. 1. Health promotion performance indicators:
The public health care posts have been carrying out the integrated health promotion project to achieve the goal of the National Health Promotion Comprehensive Plan 2020 since 2013. Therefore, in order to evaluate the effectiveness of the health promotion programs at public health care posts, it is required to develop an evaluation model to manage the health indicators proposed by the National Health Promotion Comprehensive Plan 2020 and the chronic health management indicators reflecting the primary medical care function of the public health care posts. The basic purpose of the health promotion programs at the public health care posts is to improve the health promotion of the local resident. It is necessary to improve the quality of the health promotion programs in order to evaluate the health promotion effect. A good structure increases the likelihood of a good process, and a good process can increase the likelihood of good outcomes, so the quality of care can be best assessed by linking structure, process, and outcome4. Structural assessment refers to the basic environment for physical resources such as facilities and equipment, the number of human resources. The process evaluation should include the needs of the residents, the overall process of providing health promotion services, job satisfaction of employees, and linkage of medical services. A result refers to the expected achievement or actual achievement resulting from the process. This result includes not only changes in function and well-being but also changes in knowledge, behavior, and satisfaction of the subject. The Ministry of the Interior Safety’s health and hygiene evaluation index consists of 45 indicators in five areas: emergency medical care, health promotion, disease management, infectious disease management, food∙ medicine ∙ public health and safety management. In the preceding literature, health promotion evaluation is divided into three stages: goal (target, target group, design, responsibility, resource, effort), process (network, exposure, attachment, participation), and outcome (knowledge and behavior change, environmental change, epidemiological change, persistence). In addition, evaluation frameworks were suggested as identified and evaluated, business planning evaluation, project implementation, and business impact evaluation5. Based on the Donabedian’s model, the indicators were selected based on structure, process, and outcome as shown in Table 1 [Table 1]. As a result, the structure area is about human resources, budget and resources. In the process area, the number of health educations, the number of inter-agencies between community organizations and medical institutions are selected. The health promotion result indicators that can measure the effect of health promotion performance were developed among National Health Plan indices: health life practice, chronic disease management, infectious disease management, and population health management. Smoking, drinking, exercise, obesity, and oral health were the main areas of health life practice. The areas of chronic disease management included hypertension, diabetes, high cholesterol, depression, and cancer. Infectious disease management area included immunization rate. Population health management developed evaluation index in the elderly health field. The reduction of outpatient treatment due to dementia management and instruction of drug use, and elderly activity limit reduction rate are included in population health management. Similar to the results of this study, the results of community health workers are presented in six areas of behavioral, clinical, psychological, educational, environmental and systematic aspects of patient outcomes. In particular, behavior, clinical, and psychological outcomes were the most common. Behavioral outcomes are those that lead or change patient behavior, such as drug compliance, physical activity, and the receipt of vaccines. Clinical results indicate how well the disease is controlled. Psychological outcomes are mental health states such as depression and cognitive stress management3.
|
Categories |
Evaluation indicators |
|
|
Structure |
Full-time equivalent Business cost scale Amount of project cost per person Number of institutions that can be linked officially and continuously |
|
|
Process |
Number of health education programs Connect with community organizations Connect with community medical institutions |
|
|
Result |
Health life practice |
Smoking cessation rate / Drinking reduction rate Practice rate of physical activity Prevalence of obesity Oral health care |
|
Chronic disease management |
Hypertension control Diabetes control Hyper-cholesterol control The incidence of depression Cancer checkup rate |
|
|
Infectious disease management |
Immunization rate |
|
|
Population based health management |
Dementia management Activity limit reduction rate in the elderly |
|
3. 2. Health promotion effect:
Table 2 shows the results of analyzing the public health care post program according to the health promotion performance indicators [Table 2]. As the result of analyzing the performance of the year 2014, hypertension management was the most. Next, it was analyzed that physical activity education, diabetes control, oral health and vaccination were frequently implemented. There were 12,537 annual hypertension management, 404 physical activity instruction, 301 diabetes management, 170 oral health, and 161 immunizations for each public health care post. Health care for the elderly, cancer management, obesity management, and cholesterol management were relatively low. Since the elderly health care is overlapped with other health care programs, it is difficult to measure by independent performance. Cancer patients tend to use advanced medical facilities rather than health clinics, and most of the patients who use health clinics do not seem to have many obese people because they are the elderly. In addition, it is difficult to measure the level of cholesterol at the public health care posts, so much management is not done. Not only in Korea but also in other countries, community health workers are said to lack specific roles and proven effectiveness, even though they have a great impact on the health promotion of the community. Some reasons point out that it is not enough to document the exact focus and results of the role. Therefore, in the future, it is necessary to manage and document the performance of public health care posts in detail6.
|
Evaluation indicators |
Health promotion services |
Performance (cases per year) |
|
|
Total (1,904) |
per post |
||
|
Smoking cessation rate |
Smoking cessation education |
124,630 |
65 |
|
Drinking reduction rate |
Drunk training |
145,033 |
76 |
|
Practice rate of physical activity |
Physical activity education |
770,081 |
404 |
|
Prevalence of obesity |
Obesity management |
81,117 |
43 |
|
Oral health care |
Oral health management |
323,945 |
170 |
|
Hypertension control |
hypertension management |
23,871,060 |
12,537 |
|
Diabetes control |
Diabetes management |
572,246 |
301 |
|
Hypercholesterol control |
Hyperlipidemia management |
96,771 |
51 |
|
The incidence of depression |
Mental health management |
181,289 |
95 |
|
Cancer checkup rate |
Cancer patient management |
36,272 |
19 |
|
Immunization rate |
Vaccination |
306,861 |
161 |
|
Dementia management |
Dementia prevention education |
130,836 |
69 |
|
Activity limit reduction rate |
Elderly Health Care |
924 |
0 |
This study analyzed the actual performance of health promotion program in public health care posts, based on blood pressure and diabetes levels. Blood pressure, blood sugar, cholesterol, and BMI were the only indicators that could be used to compare changes in pre-and post-program. Among them, cholesterol and BMI values were not suitable for analysis because of the large number of missing values. Therefore, the data that can be connected with the public health care post database among health promotion indicators were blood pressure and blood glucose.
An analysis of hypertension control rate of public health care post users, the control rate of hypertension was 72.9% at the first visit in 2014 and the control rate of hypertension at the last visit was 75.6%. The increase in hypertension control rate at the last visit compared to the initial blood pressure value measured in 2014 can be interpreted as the blood pressure was well controlled when the hypertension subject is managed by the public health care post. For comparison with other subjects, the last measured blood pressure in 2014 was used. That is, the blood pressure control rate measured by the last visit to the public health care posts in 2014 was 75.6%, which was 7.1%p higher than the 68.5% of the 2013 National Health and Nutrition Examination Survey. In addition, the hypertension severity of public health care post users was mild 97.1%, moderate 1.2%, and severe 1.7%. The severity of hypertension was classified based on diastolic blood pressure, mild below 92mmHg, moderate to 93-97mmHg, and severely over 98mmHg. As a result of the 2005 health screening, the blood pressure distribution rate in patients with hypertension was mild 12.4%, moderate 5.2%, and severe 82.4%7. The severity of hypertension in the public health care post users is mostly mild, indicating that hypertension is well controlled in public health care posts. In addition, this result can be interpreted that the role sharing between the private and public health care posts is well done by using the private medical institutions in the case of the severely chronic patients who are a difficult to control.
The control rate of diabetic patients using public health care posts was 85.3% at the first visit in 2014 and 86.3% at the last visit. The last blood glucose control is also related to the financial effect of increasing productivity by reducing health care costs and reducing absenteeism10. Therefore, additional analysis is required.
rate is 0.6% p higher than the first control rate. In addition, the control rate was 61.1% p higher than the result of the 2013 National Health and Nutrition Survey as 25.2% as shown in Table 3 [Table 3]. In other studies, the health promotion program in the management of diabetes has a positive effect. Especially, it is effective when the education level is low and aged8. Most of the elderly with lower education level are the users of the public health care posts, so blood glucose check and diabetes management are effective.
|
Control rate (%) |
|||
|
First visit |
Last visit |
Difference |
|
|
Hypertension |
72.9 |
75.6 |
2.7 |
|
Diabetes |
85.7 |
86.3 |
0.6 |
Chronic noncommunicable diseases have been increased due to changes in the health care environment and lifestyle and health promotion programs are the most effective to prevent these diseases. To achieve this, a health promotion strategy should be developed for each of the healthy population, population with risk factor, population with symptoms, and population with known disorder, and a holistic approach beyond traditional treatment is needed9. This role should be done by the public health care posts.
4. CONCLUSION:
Public health care posts offer many programs to promote the health of local residents. As the healthcare environment changes, the role of public health care posts shifts from primary care to health promotion. However, there is a lack of research on the effectiveness of health promotion programs in public health care posts. The objective evaluation indicators should be preceded to make a reasonable and reliable analysis of the health promotion effects. In this study, health promotion indicators for public health care posts based on Donabedian's model were developed by comparing various indicators to measure the quality of health and the achievement of health promotion. That is, detailed evaluation indicators are presented by structure, process, and results. The developed health promotion evaluation indicators provide guidelines to continuously apply the evaluation of the effectiveness of the public health care posts.
In order to evaluate the health promotion effect of the users of the public health care post, we tried to use the suggested indicators. However, the data that can be utilized through the operation status data of the public health care posts is limited to blood pressure and blood glucose measurement data of the users, so that the effect is analyzed only for hypertension and diabetes. It is difficult to understand how the health level and health form improved as a result of actually providing the health promotion program because the performance of the public health care posts is managed solely by the number of cases. In the future, it is necessary to clarify the performance indicators of the public health care posts so that the results of the public health care posts can be accurately analyzed and systematically fill out the health level of the subjects to be used in future research. Nevertheless, this study shows that hypertension and diabetes control rate of public health care post users are higher than those of National Health Insurance. The severity of hypertension in the public health care posts was also lower than that of the Nation Health Insurance data. Therefore, it is considered that the public health care posts contribute effectively to the health promotion of the people, although limited to hypertension and diabetes.
5. ACKNOWLEDGMENT:
This study was supported by the National Health Promotion Fund administered by the Ministry of Health and Welfare.
6. REFERENCES:
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Received on 12.05.2019 Modified on 17.06.2019
Accepted on 25.07.2019 © RJPT All right reserved
Research J. Pharm. and Tech. 2019; 12(11):5290-5294.
DOI: 10.5958/0974-360X.2019.00916.8