Tęstinė (nuolatinė) lėtinių neinfekcinių ligų profilaktika kaimo bendruomenėje ; Continuous (permanent) prevention of chronic non-communicable diseases in the rural community
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KAUNAS UNIVERSITY OF MEDICINE Kornelijus ANDRIJAUSKAS Continuous (permanent) prevention of chronic non-communicable diseases in the rural community Summary of the doctoral dissertation Biomedical Sciences, Public Health (10 B) Kaunas, 2006 The doctoral dissertation was prepared in 2004-2005 at Kaunas University of Medicine. Dissertation is defended extramurraly. Scientific Consultant: Prof. Dr. Leonas Valius (Kaunas University of Medicine, Biomedical Sciences, Public Health – 10 B) The dissertation will be defended at the Council of Public Health of Kaunas University of Medicine Chairman: Assoc. Prof. Dr. Habil. Regina Reklaitiene (Kaunas University of Medicine, Biomedical Sciences, Public Health – 10 B) Members: Prof. Dr. Habil. Vilius Grabauskas (Kaunas University of Medicine, Biomedical Sciences, Public Health – 10 B) Prof. Dr. Habil. Ramune Kalediene (Kaunas University of Medicine, Prof. Dr. Habil. Algirdas Juozulynas (Vilnius University, Biomedical Sciences, Public Health – 10 B) Prof. Dr. Habil. Julius Kalibatas (Institute of Hygiene, Biomedical Opponents: Dr. Habil. Juozas Kurtinaitis (Vilnius University, Biomedical Sciences, Public Health – 10 B) Prof. Dr. Habil.
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| Publié par | kaunas_university_of_medicine |
| Publié le | 01 janvier 2006 |
| Nombre de lectures | 20 |
| Langue | English |
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KAUNAS UNIVERSITY OF MEDICINE Kornelijus ANDRIJAUSKAS Continuous (permanent) prevention of chronic non-communicable diseases in the rural community Summary of the doctoral dissertation Biomedical Sciences, Public Health (10 B) Kaunas, 2006
The doctoral dissertation was prepared in 2004-2005 at Kaunas University of Medicine. Dissertation is defended extramurraly. Scientific Consultant: Prof. Dr. Leonas Valius (Kaunas University of Medicine, Biomedical Sciences, Public Health 10 B) The dissertation will be defended at the Council of Public Health of Kaunas University of Medicine Chairman: Assoc. Prof. Dr. Habil. Regina Reklaitiene (Kaunas University of Medicine, Biomedical Sciences, Public Health 10 B) Members: Prof. Dr. Habil. Vilius Grabauskas (Kaunas University of Medicine, Biomedical Sciences, Public Health 10 B) Prof. Dr. Habil. Ramune Kalediene (Kaunas University of Medicine, Biomedical Sciences, Public Health 10 B) Prof. Dr. Habil. Algirdas Juozulynas (Vilnius University, Biomedical Sciences, Public Health 10 B) Prof. Dr. Habil. Julius Kalibatas (Institute of Hygiene, Biomedical Sciences, Public Health 10 B) Opponents: Dr. Habil. Juozas Kurtinaitis (Vilnius University, Biomedical Sciences, Public Health 10 B) Prof. Dr. Habil. Apolinaras Zaborskis (Kaunas University of Medicine, Biomedical Sciences, Public Health 10 B) The dissertation will be defended at the open session of the Council of Public Health of Kaunas University of Medicine on February 24, 2006 at 11:00 a.m., in the 422 room of the Training-laboratorial building. Address:Eiveniu str. 4, LT-50166, Kaunas, Lithuania. The summary of doctoral dissertation was sent on January 24, 2006. The dissertation is available in the library of Kaunas University of Medicine. Address: A.Mickeviciaus str. 9, LT-44307, Kaunas, Lithuania.
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KAUNO MEDICINOS UNIVERSITETAS Kornelijus ANDRIJAUSKAS Tęstin(nuolatin) ltiniinickefnienligprofilaktika kaimo bendruomenje Daktaro disertacijos santrauka Biomedicinos mokslai, visuomens sveikata (10 B) Kaunas, 2006
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Disertacija rengta 2004-2005 metais Kauno medicinos universiteto eimos medicinos klinikoje. Disertacija ginama eksternu. Mokslinis konsultantas: prof. dr. Leonas Valius (Kauno medicinos universitetas, biomedicinos mokslai, visuomens sveikata 10 B). Disertacija ginama Kauno medicinos universiteto Visuomens sveikatos mokslo krypties taryboje Pirmininkas: doc. habil. dr. Regina Rklaitien medicinos universitetas, (Kauno biomedicinos mokslai, visuomens sveikata 10 B) Nariai: prof. habil. dr. Vilius Grabauskas (Kauno medicinos universitetas, biomedicinos mokslai, visuomens sveikata 10 B) prof. habil. dr. Ramun Kaldien (Kauno medicinos universitetas, biomedicinos mokslai, visuomens sveikata 10 B) prof. habil. dr. Algirdas Juozulynas (Vilniaus universitetas, biomedicinos mokslai, visuomens sveikata 10 B) prof. habil. dr. Julius Kalibatas (Higienos institutas, biomedicinos mokslai, visuomens sveikata 10 B) Oponentai: habil. dr. Juozas Kurtinaitis (Vilniaus universitetas, biomedicinos mokslai, visuomens sveikata 10 B) prof. habil. dr. Apolinaras Zaborskis (Kauno medicinos universitetas, biomedicinos mokslai, visuomens sveikata B) 10 Disertacija bus ginama vieame Kauno medicinos universiteto Visuomens sveikatos mokslo krypties tarybos posdyje 2006 m. vasario 24 d. 11 val. KMU Mokomojo-laboratorinio korpuso 422 kab. Adresas: Eivenig. 4, LT-50166, Kaunas, Lietuva. Disertacijos santrauka isista 2006 m. sausio 24 d. Disertacijągalima perirti Kauno medicinos universiteto bibliotekoje.
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Adresas: A.Mickevičiaus g. 9, LT-44307, Kaunas, Lietuva.
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CND RF ABP BMI IHDAH DM CI WHO
ABBREVATIONS
chronic non-communicable diseasesRF arterial blood pressure body mass index ischemic heart diseasearterial hypertension diabetes mellitus confidence interval World Health Organization
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INTRODUCTION Chronic non-communicable diseases (CND) become the reason of 50 percent of deaths in the welfare societies. The World Health Organisation (WHO) has indicated that in the 2025 CND, especially cardiovascular diseases will remain the most important health problem in Europe and in the world [The World health Report, 1998]. The mortality rates from IHD, as well as overall mortality in Lithuania, increased since 1995, a tendency for decrease during the last decade has been observed. According to the Lithuanian Statistics, the mortality rate from IHD in 2001 was 628.2/100000 inhabitants per year [Lithuanian Ministry of Health, 2004by quarter as compared to 1995; nevertheless, the mortality]. It decreased almost rates from IHD in Lithuania exceed the average (mean) of the European Union countries nearly by two fold [WHO Data Base, 2003]. The investigations in the world, as well as in Lithuania have shown that the risk factors (RF) of the CND are common for all the CND [V.Grabauskas, 1995, IU.Haq,1999In Lithuania the epidemiological research on CND has]. been performed in the context of the international integrated preventive program on non-communicable diseases (CINDI) [J.Petkevičien, 1994, J.Klumbien, 1999]. Therefore, the role of the family doctor in the primary prevention of CND, especially the ischemic heart disease (IHD), becomes very important in a certain community. The investigation in Lithuanian have shown that every second 35-64 year old man or woman suffers from arterial hypertension (AH), every tenth has ischemic heart diseases, every second man and every eighth women smokes, more than 4/5 of the population consume alcohol, ¾ men and women have elevated blood cholesterol level, etc. [J.Petkevičien, 1997, J.Klumbien, 2002, A.Tamoinas, 1999, 2005]. AH as one of the main RF of the cardiovascular diseases accounts for 20-50 percent of overall mortality [The World health Report, 1998]. Epidemiological studies have demonstrated a strong association between the AH and the cardiovascular risk [T.Jackson, 2000]. Hypertensive persons more often suffer from myocardial infarction, stroke, atherosclerosis of extremities as compared, to normotensive ones [D.Satkien, 2001]. AH very often is accompanied by the other RF: dyslipidemia, smoking, overweight, glucose intolerance. AH, together with the other RF, ten times increases the mortality from IHD rates [W.B.Kannel, 1996, 2000]. The important objective of the primary health care reform is health training and diseases prevention. The institution of the family doctor (family doctor in a team) has the possibilities to fulfil this task: the accessibility of the population with all health problems, high clinical competence, facility succession, orientation to personality needs, holistic approach to personal health problems, permanent and immediate contact with the community, cooperation with a patient and, finally, - the role of "scapegoat" in the Lithuanian health care system - increase the level of personal and the communities health problems acknowledgement and the possibilities to influence them. The prevention is less consuming than healing the diseases and complications. It is more cost effective for the state to resource the institution of family doctor to embrace the person and the community to take care of health and to prevent the development of the CND. We found a lack of the investigations in the field of the efforts of the family doctor in health promotion and the prevention of the diseases, especially working in a team, in the integral prevention of the CND, covering all age categories from birth to senescence. By the way, the composition of the family physicians team in Lithuania is not determined and the model of the activities in health training and prevention in the community is not created. The activity of the primary health care system in the filed of health promotion, education and prevention is insufficient. The main reasons: the family physicians work overload, lack of motivation to fulfil this task, the population attitude towards health and the lack of organisational knowledge. The CND primary prevention is included into the primary health care institutions health promotion, education and prevention activities, demands
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permanent integrated CND RF correction and the efforts for detection and the correction of the CND RF. This preventive action should be carried out by the family physicians teams, according to science and practice based methods. THE AIM OF THE STUDY The aim of the study was to assess the possibilities of the family physicians institution to implement the permanent integrated prevention of the chronic non-communicable diseases and health promotion in the rural community. Objectives: 1. To assess the self-rated health of the Kaltinnai community, its dynamics and the relationship with sociodemographic and chronic non-communicable diseases risk factors in 2004 by implementing the permanent chronic non-communicable diseases prevention using team work approach. 2. To determine and assess the prevalence of the chronic non-communicable diseases risk factors in the Kaltinnai children and adults population in 2002-2004. 3.To compare and evaluate frequency of provided recommendations by primary health care team on non-communicable diseases risk factors and healthy lifestyle principles, and prevalence of risk factors and their average scores in the intervention and the control groups.4.To assess the effectiveness of primary health care team activities according to the population attitudes towards nutrition and the prevalence of the chronic non-communicable diseases risk factors and changes in their average scores in the six year period (1998-2004).The scientific novelty of the study For the first time in the Lithuanian public health science history the effectiveness of the family physicians team work approach to implement the permanent chronic non-communicable diseases integrated prevention program and health promotion in the rural community was determined and evaluated. It is a lack of the investigations in the field of the family physicians institution activities in health promotion and the prevention of the diseases, the team work approach effectiveness in the integrated prevention of the CND, covering all age categories from birth to senescence was not evaluated. By the way, the composition of the family physicians team in Lithuania is not determined and the model of the activities in health education and prevention in the community is not created.
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MATERIAL AND METHODS Study population The investigated contingent comprised 1200 inhabitants in the Kaltinnai settlement 18 years and over who were prescribed in the Kaltinnai primary health care centre in 1998 and 670 children 6-18 years of age, prescribed in the Kaltinnai primary health care centre in 2002. The persons (N=800) additionally prescribed in the Kaltinnai primary health care centre during the first quarter of 2002 (to provide the reorganization of primary health care institutions in the rural region, connecting rural medicine stations of outlying region in the distance of about 10-15 km from the Kaltinnai primary health care centre) composed the control group. The study was performed in 1998, 2000 and 2004 years. From investigated population (N=1200) in 1998 participated in the study 1161 persons - 474 (40.8%) men and 687 (59.2%) women (response rate 96.8%), in 2000 participated in the study 1056 persons - 446 (42.2%) men and 610 (57.8%) women (response rate 88.0%) and in 2004 1019 persons 396 (38.9%) men and 623 (61.1%) women) of Kaltinnai 18 years and over participated in the study (response rate 84.9%). In 2004 562 children of Kaltinnai rural community (258 (45.9%) boys and 304 (54.1%) girls) 6-18 years of age participated in the study (response rate 83.9%). The control group composed 368 persons, randomly selected from the additionally prescribed persons (N=800) (sorting every second). 32 (8.7%) persons of the control group (dead or leaving from this rural region) were excluded from the analysis. The control group did not participate in the primary CND prevention program from 1998 to 2005. The average age of the control and intervention groups did not differ significantly and was 56.8±0.94 and 58.01±0.54 years (p=0.07), respectively. The sociodemographic data (marital status and education) of the control and intervention groups did not differ significantly. Methods and criteria The data analysed in the study comprised: 1) socio-demographic variables: gender, marital status, education, occupation 2) anamnesis data: self-perceived health status, anamnesis of the main CND RF, 3) examination on possible RF (Arterial blood pressure (ABP), BMI, cholesterol level) and behavioural RF, nutritional status, and etc., 4) the possibilities of family physicians and patients self-control of the ABP, body weight, nutrition habits 5) the patients knowledge about the CND RF and tendencies in their attitudes towards the impact of primary health care institutions in the correction of the CND RF. I Stage. Primary interview of the population.In1998 the questionnaire interview has been performed. The questionnaire information covered the attitude of the rural community towards health status, absence of the measured and declared CND RF (ABP, BMI, smoking, immoderate alcohol consumption, occupational status). After the primary data analysis the meeting with the Kaltincommunity was organized and the results werenai presented: 1) prevalence of CND RF, 2) nutritional habits in the community, 3) the methods of CND RF prevention and correction were displayed, 5) the members of the rural community were invited to the active participation in resolving their health problems. II Stage.Primary health care team training before starting the preventive program of the CND RF. Preparingfor impact primary health care team approach organization and active participation in the primary CND RF prevention, according to WHO recommendations, practical recommendations for the primary CND RF prevention and RF evaluation standards were prepared. According to the above-mentioned recommendations, the community nurses were trained in the prevention principles of the rural community.
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Training seminars covered 13 academic hours (the seminars were organized in Kaltinnai primary health care centre in 1998 January-April). Every three months the community nurses were invited to participate in reflection meetings, resolving certain situation. 2 academic hours per month were devoted to the additional individual consultations. Besides, twice a year the meetings of the primary health care team with the members of the Family medical clinic of the University of Medicine have been organized and the problems in the prevention program of the CND in the rural community have been discussed. The seminar practice showed that the theoretical information is not sufficient for qualitative work performance, therefore the team gathered monthly in 1-2-hours meetings. Consultants were available in the resolving of complicated methodological difficulties (once a quarter the first year and 1-2 times per year later, the last 2 years the consultants arrived once a year). III Stage. Control of CND RF.Since 1998 when the CND prevention program started the rural community experienced those methods of prevention: 1) impact to the whole community, training in healthy lifestyle, 2) determination and evaluation of RF, 3) choice of preventive methods: individual or group work with the inhabitants in RF correction, 4) preparation and application of preventive measures: letters, press, lectures, seminars, 5) preventive work with definite groups: adults, children, adolescents, 6) individual work with persons, possessing RF. IV. Stage: Final stage, final screening and the evaluation of the preventive programs results.In the CND preventive program evaluation process, every person during the visit to the primary health care centre in 2004 was asked to fill in the additional questionnaire, as well as persons visited at home by the community nurse. Data was stored in the data set, created with the help of MS Access. The principle of independence was set in the work organization of the family doctor and the community nurses. Previous position of the community nurse as the doctors assistant or in the narrow field (as physiotherapist nurse, paediatrician, obstetrics or reception) was changed. The community nurse was educated to take the partial responsibility, to fulfil the independent job, full of creativity. Family doctor was responsible for early diagnosis of arterial hypertension: adults were assigned individual pharmaceutical and non-pharmaceutical recommendations; children were investigated seeking to disclose the primary reason of the AH development (diagnosis of symptomic AH, after exclusion methods of correction). Every nurse was retrained to a community nurse according to the foreseen schedule. The community nurses divided all the inhabitants according to districts, in families. The place of residence of the community nurse was as close as possible to the attendant territory. Methods of communication with the population:individual (every meeting). The community nurses are supplied with the prepared recommendations on AH, nutrition habits, adapted for the rural population; community meetings in church after prayer, school meetings, etc. lectures, discussions about health, local media (2 articles have been prepared in the first year, afterwards 1 article every year). In 2001 a letter has been published with wide description of the purposes of the prevention, the results obtained, and practical recommendations.Intersectorial collaboration. Representatives of church were included into the process. The Kaltinnai community members were allowed to attend the parish rehabilitation centre. Very often the priest measured the ABP during the visit at home, talked about health problems. The parish hall was permitted to use for the community meetings with the medical staff, the priest participated in the meetings himself. For the release of health information very effectively were used a school, employees of post office, milk selection centre, municipal representatives and active members of the community.
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The CND prevention program in the rural community in 2002 included children and adolescents as well. They were investigated in respect to possible RF, e.g., they were asked on smoking habits, alcohol consumption, nutritional habits, physical activity, perceived health, diagnosed AH, family anamnesis on AH. The measurement of ABP has been performed. The adopted by prof. A.Zaborskis WHO questionnaire on the determination of the possible RF was used for children as well as for adults. Twice a year the meetings with the children and adolescents were arranged (often at school), they were informed about the possible harmful effects of the CND RF on young organism, the advantages of healthy lifestyle for personal and public health. Hypertensive pupils were investigated twice a week. Children with AH underwent special preventive program with the optimisation of physical load and rest, regulation of nutritional habits. Pupils with secondary AH were sent to specialist examination. Since the beginning of the program, the school nurse was included in the prevention, since 2003 the school public health specialist. Twice a year in the meetings of pupils and their parents the lectures on CND and the RF were offered. Data on children health status were disclosed in the seminars; discussions on health problems and health improvement were arranged. When the community nurses detected CND RF, they invited those persons to visit the family doctor in the Kaltinnai primary health care centre. Consultations were accompanied by the examinations, e.g. measurement of the cholesterol and glucose level, intraocular pressure. The pharmaceutical as well non-pharmaceutical measures were prescribed. The community nurses followed the patients according to the instructions of family doctor, took responsibility for the continuous and permanent care, consulted on the principles of healthy nutrition, non-pharmaceutical methods of the CND RF correction. The community members had the possibility in ABP measurements and CND RF correction at home. For this purpose the community nurses devoted 1 hour (from 2 hours in the work schedule) for the needs of the community. To ensure the active participation of the community in the process, the Kaltinnai primary health care centre team organized and is organizing the meetings with the community. The meetings take place twice a year: before the spring jobs and after autumn jobs. In the meetings they have lectures and discussions about CND RF, harmful health effects, the personal and communal possibilities in their correction; the team approach of the primary health care centre is being disclosed. The primary health care centre staffs, representatives of municipal and non-governmental organizations (church, school) are participating in the discussions. The teamwork organizational principle includes the working hours of the family doctor and the community nurses in the primary health care centre and visiting the people at home twice a year. During the visits the measurements of the ABP have been performed, the BMI was evaluated, health behaviours, nutrition, occupation type were analyzed. All the participants of the study underwent the measurements of the ABP (in the primary health care centre or at home). The community nurses performed the measurement after the standardization process according to the WHO recommendations (right hand, sitting position, accuracy of 2 mm/Hg). Systolic and diastolic blood pressure was determined according to the Ist and Vth tonesV.Korotkov. The ABP was measured 3 times every 3 of minutes. In the evaluation process the average score of 3 measurements has been calculated. The elevated blood pressure or AH has been determined, if the systolic blood pressure was ≥140 mm Hg and/or diastolic AKS≥90 mmHg, or normal arterial blood pressure (<140/90 mm Hg), accompanied the administration of hypertensive drugs. Arterial blood pressure for children was determined according to the dr. J.Bojarskas (with co-authors) table. Body weight was measured by medical balance, accuracy of 100 g. The weighting process was performed without shoes and upper clothes. Body height was measured by the medical
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