The Study Of Behavioral Intervention On Noncommunicable Disease Risk Factors Control Based On Health Promotion

Study backgroundWith rapid socioeconomic development, population aging and disease model change, non-communicable chronic disease (NCD) has become the main health threat to rural and urban residents. The continuous increase of NCD patients leads to the escalation of health loss and disability caused by NCD, which aggravates the health inequity and social disease burden, therefore, the government has pay more attention to NCD control. Many high-technologies are applied to control NCD in developed countries, however, the cost is high, and the result is not as expected. Then, some people think high risk population control is economic efficient, and the perspective is changed from therapy to prevention, but the result is disappointing. In the end, the control strategy is changed to whole population control. Result of studies on NCD pathogenesis chain shows that proximal risk factors (e.g., hypertension, hyperglycemia, obesity and overweight) and intermediate risk factors (e.g., unhealthy diets, lack of activities and excessive drinking) are correlated with NCD incidence, however, the correlation of distal risk factors, such as social, economic, cultural and environmental factors, is higher. Now, the whole population strategy is to control the intermediate risk factors, and distal risk factors are neglected. Hence, we should control the proximal risk factors to control NCD, and at the same time, intermediate and distal risk factors should be controlled too.Health promotion strategy is the most efficient NCD control strategy, whose intervene points are two types of health determinant factors:one includes social, economic and environmental factors; and the other includes personal healthy behavior. The evidences from UK, USA and Finland show that interventions on social determinant factors are efficient for NCD control. China has designed a comprehensive strategy, which includes whole population strategy, high risk population strategy, health promotion strategy, community prevention strategy, which obtains some experiences, however, the effect is no as expected. First, the NCD morbidity keeps at a high level. Although we input so much to control NCD, the morbidity and mortality of NCD is still high. Second, the NCD risk factors are not controlled efficiently. The study result of public health strategic group of <Healthy China2020> shows that China loses control of NCD risk factors. Third, NCD public policies are lacked. Some policymakers, especially non-health department's policymakers, don not realize the function of tobacco, nutrition, activities and alcohol related public policies in NCD control. Fourth, supportive environment of NCD control is lacked. In addition, the form and content of health promotion need to be improved.Study objectiveFirst, we summarize national and international NCD control experiences; then, based on health promotion theory, we design a health promotion intervention model targeted on NCD risk factors and social determinant factors; third, we implement this intervention in rural areas of Shandong province. In this study, we investigate how health promotion strategy is implemented, evaluate the intervention impact, analyze the pathway between health promotion and NCD risk factors, discuss the effect factors of NCD control, in the end, we make policy recommendation on how to control NCD risk factors through health promotion.Study MethodsSampling:According to socioeconomic and geographic status, three counties are selected:Tengzhou, Yiyuan, Ju county. Multi-stage stratified method is used to select intervention population. Three towns are selected from each county, two villages are selected from each town, and the survey population should be permanent residents more than25. On October,2010, we collect baseline information, in total,1261residents are surveyed. On June,2011, we collect impact information, in total,936residents are surveyed.Tools:One is household survey, the main content of which is demographic and economic status, personal living styles, health related knowledge and so on. The other is facility survey, the object of which is county CDC, township health centers and village clinics. The content includes local health system situation, socioeconomic index, resources and policies of NCD control, community participation, training, supervision and so on. Data entry and analysis:MicrosoftAccess2003is used to data entry, SPSS16.0is used to descriptive analysis, AMOS7.0is used to analysis the pathway of intervention impact, and HLM7.0is used to analyze the effect factors of intervention impact.Study results(1) situation of health promotion strategy implementation:In total, there are38documents about NCD control, which includes11comprehensive and special plans,27NCD risk factors control documents. In2010, the NCD control funds (without basic public health service funds) of Tengzhou, Yiyuan, and Ju county are180,000,100,000, and60,000respectively. There is a large difference among three counties. All the three countries build rural residents' sports activities centers. In pilot areas, there is different level participation of communities in the field of NCD plan design, health education, smoking-free environment building and other healthy living styles activities. In pilot areas, county hospitals and township health centers provide personal NCD control ability training. Three tiers health facilities provide different health education service to high risk population and general population.(2) The impact of health promotion strategy to residents'NCD related knowledge:the intervention, the rate of knowing hypertension risk factors among target population increases from27.1%to46.6%; the rate of knowing diabetes risk factors among target population increases from24.1%to30.9%; the rate is higher among men compared with women, and the same situation among young men compared with the olds, the rate decreases with the age increases. The rate of different sexes and age groups all increases after the intervention, the differences have statistical meaning.(3) The impact of health promotion strategy to residents'unhealthy attitudes:About attitudes towards smoking cessation, the rate of people who thinks smoking is harmful, smoking in public is impolite, smoking habit can be stopped increases after intervention; About attitudes towards drinking cessation, the rate of people who thinks excessive drinking is harmful, excessive drinking habit can be stopped increases after intervention, however, the rate of persuading others to drink little does not change after the intervention. About attitudes towards physical activities, the rate of people who thinks physical activity is good to health, who can keep exercising, and who wants to get advice from doctor's increases after intervention. About attitudes towards healthy diet, the rate of people who thinks diets has correlation with health, which can control the salt intake, increases after the intervention; however, the rate of people who can control oil intake every day does not change after the intervention.(4) The impact of health promotion strategy to residents' unhealthy behavior:The smoking rate decreases from25.6%to22.4%after the intervention, however, the difference has no statistical meaning; after intervention, the cigarettes number and smoking cessation rate among men increase. The drinking rate decreases from42.2%to37.9%after the intervention, however, the difference has no statistical meaning; after intervention, drinking cessation/limit rate, the rate of people who drink beer, and the drinking frequency every week increase, however, the wine volume drinking every time decreases. More people who stop or limit drinking for the reason of disease prevention. The physical activities rate increases from12.5%to16.3%after the intervention, and walking is the main form of activity; rate of people who do exercises1to3times every week is higher after intervention. The healthy diet rate increases from13.5%to17.6%after the intervention, and the rate of people who eat more salt, sugar and oil is lower after intervention.(5) The pathway analysis of health promotion strategy intervention impact: Pathway analysis model is applied to analyze the impact between demographic status, knowledge, attitude and behavior. The result shows that the older, the behavior change is harder, OR value is-0.007. Attitude is the most important variable to behavior change, OR value is-0.66. The effect level of knowledge and education degree is intermediate. The least effect factor is annual income per capita. Through standardized coefficient of pathway analysis, we can find the most efficient measure to change behavior, implement targeted risk factors intervention, and improve the impact of NCD behavior intervention.(6) The effect factors analysis of health promotion strategy intervention impact:Personal variables are nested in social variables, so traditional linear regression model can not be used. In our study, two levels multilayer linear model is used to analyze the impact of social variables and personal variables to NCD risk factors control. In our model, the first level is intervention objects; the second level is villages where the objects live, the characteristics of county and town are added into village to estimate the effect and direction. The first level random regression model result shows, age, knowledge, and attitude can affect the behavior, however, the effect of age has no difference among different villages; the effect of education has no statistical meaning, however, it has statistical meaning among different villages, hence, education is added into the second level model. The second level random regression model result shows, community participation will reinforce the effect of education to behavior change, and OR value of education is0.0374; community participation will reinforce the effect of NCD knowledge score to behavior change, and OR value of education is0.087; supportive environment will reinforce the effect of attitude to behavior change, and OR value of education is0.041; improving health skills will reinforce the effect of attitude to behavior change, and OR value of education is0.078.Conclusion and Policy recommendationsThe incidence of NCD risk factors is high relatively in rural areas of Shandong province, such as smoking, excessive drinking, lack of physical activities, and unhealthy diet. It is imperative to study how to control these risk factors to decrease the incidence of NCD. In this study, we design four types of NCD risk factors intervention from perspective of policy making, environment support, and community participation, personal health skill based on health promotion. Through impact evaluation before and after the intervention in pilot areas, we find that health promotion control strategy is implemented well relatively, risk factors are improved, and health promotion intervention impact pathway and effect factors are identified. The result shows health promotion is an economic efficient intervention model to prevent NCD risk factors. It focuses on intermediate and distal part of pathogenesis chain through changing unhealthy behavior and social determinants based on scientific theory.We also find that health promotion and intervention should be improved in practice, and impact should be reinforced, hence, to improve the impact of NCD risk factors control, we make policy recommendations as follows: NCD health promotion strategy should arouse common view of the whole society; NCD health promotion activities should be guaranteed by definite policies; prevention of NCD should be paid more attention; public health service function should be reinforced in rural basic level health facilities; rural residents' participation should be improved.