PHWR Public Health Weekly Report

The Korea Disease Control and Prevention Agency (KDCA), formerly the Korea Centers for Disease Control and Prevention (KCDC), has conducted an annual Community Health Survey since 2008 to assess the health status of local residents. These surveys have consistently revealed significant regional disparities in health indicators related to chronic diseases, with certain areas showing deteriorating health metrics and increased health disparities. This pattern underscores the urgent need to determine the factors that can reduce health disparities and then devise targeted strategies to address the unique needs of different regions by initiating projects aimed at remedying these region-specific health disparities. Notably, local governments have persistently advocated initiatives to assess the health conditions of residents in subregions, which are areas smaller than districts within the administrative hierarchy (si-gun-gu), and address health disparities within these areas.

Therefore, in response to this governmental advocacy, the KCDC announced the launch of the “Subregional Health Disparity Reduction Pilot Project” in August 2019. This project aimed to identify the key determinants of health disparities in each subregion and develop targeted strategies reflecting the unique characteristics of each area to mitigate these disparities and promote the health of the residents. Since 2020, the project has focused on reducing health disparities at the subregional level, particularly among vulnerable populations, to improve overall community health outcomes. These vulnerable subregions are pivotal for the project’s success, as these areas embody the broader community challenges that hinder the promotion of health and the reduction of disparities across the community. The Subregional Health Disparity Reduction Project is designed as a region-led initiative, with the aim of establishing a successful local health project as the standard model for future projects.

In September 2020, following the conversion of the KCDC to the KDCA, the Gyeongnam Regional Center for Disease Control and Prevention was established in cooperation with the Gyeongnam Regional Government to serve as a regional hub for public health. This report aims to present the status and accomplishments of the Gyeongnam Subregional Health Disparity Reduction Project, which is spearheaded by the Division of Chronic Disease Survey of the Gyeongnam Regional Center for Disease Control and Prevention in cooperation with the Regional Government.

The Subregional Health Disparity Reduction Project was implemented within regions through a process in which the KDCA selected the project regions, the municipalities, and provinces recommended candidate subregions to headquarters, and the Project Region Selection Committee then finalized the subregions.

The project targeted subdistrict level (dong-eup-myeon) areas or their equivalent within district-level communities (si-gun-gu), in which the residents’ subjective health status and health-related quality of life were evaluated as the final project performance indicators.

The project was implemented in three phases spread over three years, each aligned with specific annual goals. The initial phase (Year 1) centered on assessing the health status of the target population within the designated subregions to identify the causes of disparities and develop appropriate intervention models. These intervention projects were launched during the second phase (Year 2). The concluding phase (Year 3) focused on evaluating the interventions and formulating strategies for broader dissemination (Figure 1). This report presents an analysis of the progress and key outcomes of the Subregional Health Disparity Reduction Project conducted by the Gyeongnam Regional Center for Disease Control and Prevention (specifically, its Chronic Disease Investigation Department) from 2020 to 2023, and it considers future directions for subregional health disparity reduction projects in the Gyeongnam region.

Figure 1. Projects step for Subregional Health Disparity Reduction (3 stages)

1. Progress of the Gyeongnam Subregional Health Disparity Reduction Project 2020–2023

The Gyeongnam Subregional Health Disparity Reduction Project comprised a total of four individual projects that were selected and implemented over four years: two in 2020 (in Ulsan Nam-gu and Gyeongnam Namhae-gun), one in 2022 (Busan Nam-gu), and one in 2023 (Gyeongnam Goseong-gun) (Table 1).

Table 1 Subregional Health Disparity Reduction Project in Gyeongnam local area (2020–2025)

Priod (perform)	Si-do	Region (city, county, district)	Subregion (eup‧myeon, dong)	Title	Subject	Strategy	Goal	Content
2020–2022 (complete)	Ulsan metropolitan city	Nam-gu public health center	Samho-dong	Samho-dong health safety net to reduce Subregional Health Disparity 『Samho Ya-Ho Health Intensive Management Project』	Samho-dong residents: 20,981 (6.5% of all Nam-gu residents)	(Step 1) Select subregions with health vulnerabilities, analyze and confirm in-depth health status, and develop intervention project model. (Step 2) Pilot application and improvement of the established project model. (Step 3) Evaluate the effectiveness of the intervention project and prepare a strategy to expand it to other regions.	(Health results). Health level awareness rate. Health-related quality of life index (EQ-5D). (Health determinants). Walking practice rate. Treatment rate of people diagnosed with high blood pressure (≥30). Treatment rate of people diagnosed with diabetes (≥30). Annual health facility utilization rate. Overall safety level.	(1st to 3rd years). (High-risk approach). Identifying subjects. Program connection and implementation. Tracking management. (Population approach). Laying the foundation for creating a healthy environment. Implementation of healthy environment creation. Establish a collaboration system.
	Gyeongsangnamdo	Namhae-gun public health center	Samdong-myeon, Changseon-myeon	Physical capacity strengthening project to manage chronic diseases of the elderly	567 seniors aged 65 years or older		(Health results). Health level awareness rate. Health-related quality of life index (EQ-5D). (Health determinants). Proportion of good physical activity performance. Improving the quality of life (physical and mental areas) related to the health of the elderly. Elderly nutrition index improver fraction. Proportion of people maintaining high blood pressure and diabetes within normal range. Proportion of people taking regular medications for high blood pressure and diabetes. Excellent practice autonomy in nutrition and physical activity. Performance rate of linkage with related organizations. Program completion rate.	(1st to 3rd years). Basic survey and subjects health level. Building a cooperative network. Nutrition business (strengthening physical functions). Physical activity (strengthening physical functions). Home visit health care project (improvement of health care ability). Comprehensive evaluation and care plan linked to medical institutions establishment (improvement of health management ability).
2022–2024 (2nd year)	Busan metropolitan city	Nam-gu public health center	Yongho 3-dong	Wise K-Health Community, Yongho	1,000 people aged 30 or older at high risk for chronic diseases (7.8% of all residents in Yongho 3-dong)		(Health results). Health level awareness rate. Health-related quality of life index (EQ-5D). (Health determinants). Recognition rate of early symptoms of cardiovascular disease. Depression experience rate. Social environmental awareness rate.	(1st to 2nd year). Building a cooperative network. Basic survey of local community status. Public discussion of local health issues and establishment of intervention project plan. Applying multi-level health intervention programs based on cooperation with local resources (close to residents, forming a healthy community, establishing a health-friendly ecosystem).
2023–2025 (1st year)	Gyeongsangnamdo	Goseong-gun public health center	Sangni-myeon, Maam-myeon	Community-centered customized health care service project	Seniors over 60 years old (997 people in Sangni-myeon, 1,060 people in Maam-myeon)		(Health results). Health level awareness rate. (Health determinants). Walking practice rate. Blood pressure level recognition rate.	(1st year). Basic survey of subregion (Sangni-myeon, Maam-myeon) status and health level diagnosis. Identify the causes of health disparities between regions (quantitative survey and qualitative focus group survey). Creation of a healthy village environment (construction of a village health council, health leader education, development of a walking course, operation of a walking competition and health promotion booth). Draft intervention program (health class for senior citizens, walking club) pilot implementation.

EQ-5D=Health Related Quality of Life..

The Gyeongnam Regional Center for Disease Control and Prevention jointly promoted region-specific projects in cooperation with municipalities and provinces through participation in the regional steering committee and actively supported them by conveying the demands of local governments to the KDCA to enable policy feedback.

1) Samho-dong, Nam-gu, Ulsan: Samho Ya-Ho Intensive Health Management Project for building a health safety network in Samho-dong to reduce subregional health disparities (2020–2022)

This project, which engaged 20,981 adults aged 19 and over (6.5% of the total population of Nam-gu, Ulsan) over the duration of three years (2020–2022), was carried out in collaboration with the local community, and it centered around community health centers, based on the project phases and target population groups (Table 1). The project in the Samho-dong area focused on chronic disease management and a walking campaign, and it employed a multidimensional approach comprising a “high-risk approach” and a “population group approach.” This multidimensional approach was tailored to the health status outcomes of the project’s target groups.

In the high-risk approach, the target study subjects were identified through health status surveys and connections with the National Health Insurance Service, community health centers, and healthcare providers. Furthermore, this approach involved integrating and operating chronic disease management programs by referring untreated cases to hospitals and monitoring the medication of those under treatment, educating patients on diseases, nutrition, exercise, and other health practices, providing educational incentives, and conducting follow-up management through case management and participatory health behavior improvement strategies.

The population group approach was designed to foster a healthier environment by evaluating the local environmental conditions, establishing networks with partner organizations, analyzing walking programs from other regions, and implementing walking programs led by residents. Further efforts to create a cooperative framework involved organizing local promotional activities and campaigns, holding expert advisory meetings, and arranging community gatherings and performance events. These measures aimed to mitigate the health disparities between this area and the Ok-dong area, which served as a comparison group, by deploying targeted health promotion initiatives and employing both multilevel and multidimensional methodologies (Figure 2) [1].

Figure 2. Project model for Subregional Health Disparity Reduction of Gyeongnam local area

2) Samdong-myeon and Changseon-myeon, Namhae-gun, Gyeongnam: Community-centered Customized Health Management Service Project (2020–2022)

This project, which was conducted over three years (2020–2022), engaged 567 citizens aged 65 and older residing in Samdong-myeon or Changseon-myeon, Namhae-gun, Gyeongnam. It was executed utilizing an integrated community care intervention model with the aim of preventing frailty and enhancing disease management capabilities through the enhancement of physical functions. Older citizens in the project areas (Samdong-myeon and Changseon-myeon) engaged in multidisciplinary exercises, including aerobic, strength, and balance exercises designed to combat sarcopenia and frailty, and these exercises were led by the residents themselves (exercise interventions). Direct nutrition support, including protein supplements, was provided along with nutritional counseling and education (nutritional interventions) for individuals with poor nutrition scores. Furthermore, comprehensive health assessments of older adults and medication management for those with multiple chronic conditions were carried out by local primary healthcare facilities (comprehensive medical assessment). This comprehensive medical assessment linked the outcomes of medication management and overall health assessments to visiting health services and health clinics (home care interventions). In essence, the residents, healthcare facilities, and public agencies collaborated as caregivers for the health of older citizens in the project areas, with the visiting services of community health centers monitoring the overall project progress and providing direct services. This integrated community care intervention model sought to reduce health disparities between the target populations in the project areas and the entire Namhae-gun population (the comparison group) (Figure 2) [2].

3) Yongho 3-dong, Nam-gu, Busan: Yongho, Wise K-Health Community (2022–2024)

Nam-gu, Busan, aimed to enhance the health levels of residents in Yongho 3-dong by identifying health risk factors related to health behavior and environment and applying intervention models based on these findings. In the first year (2022), a collaborative governance structure was established to ascertain the health status and determinants of health issues within Yongho 3-dong. A mixed methods approach that included focus group interviews, participatory community environment surveys, and health status assessments was employed for this purpose. Activity plans were formulated following an analysis of the underlying causes of each health issue. These plans led to the development of intervention project models. In the second year (2023), the project focused on the stable operation of local governance and supported community-based health activities. It provided integrated health management services tailored to community needs and conducted performance measurements and mid-term evaluations of the intervention projects. Efforts to refine the intervention models were undertaken through consultation with public health experts and community stakeholders. The third year of the project (2024) is dedicated to reducing health disparities between the project area and Yongdang-dong and the whole of Nam-gu, which serve as comparison groups, by implementing the developed intervention models (Figure 2) [3].

4) Sangri-myeon and Maam-myeon, Goseong-gun, Gyeongnam: Community-centered Customized Health Management Service Project (2023–2025)

In an effort to establish strategies for addressing health disparities in Sangri-myeon and Maram-myeon, Goseong-gun, Gyeongnam, this project aimed to develop intervention models by identifying the causes of health issues among residents aged 19 and above in Sangri-myeon (n=1,578) and Maram-myeon (n=1,700). In the first year (2023), the project involved analyses of environmental and demographic data in the project areas, community health surveys, National Health Insurance Service Data, and case studies of Korean and international walking programs. To foster resident-led participation, meetings and village gatherings were organized, and a village health council was established. Health leader training programs were launched to further increase the project’s effectiveness, and programs were operated at senior welfare centers to provide tailored health consultations and education to marginalized health groups within the project areas. Based on focus group interviews, in-depth surveys on physical activity and walking compliance rates were conducted, as was an in-depth analysis of the local context and health facilitators and barriers. Furthermore, the program needs of the residents were identified, leading to the development of intervention programs (such as walking clubs and health leader training). The resident-led intervention program “Let’s Walk Together! Walking Around the Neighborhood” was implemented, and it was complemented by a residents’ health walking contest, the creation of walking posters featuring local residents, and health promotion campaign booths. In the second year (2024), the project aims to enhance the health levels of the residents and reduce health disparities between these areas and the broader Goseong-gun area by developing sustainable community-centered intervention models (Figure 2) [4].

2. Key Achievements

1) Samho-dong, Nam-gu, Ulsan

Nam-gu, Ulsan, developed an intervention model based on the multidimensional approach comprising the high-risk and population group approaches (Figure 2). Two health outcome performance indicators were set in this project: the “subjective health status awareness rate” and the “Health-Related Quality of Life Index (EQ-5D).” Furthermore, five performance indicators were set for health determinants: walking compliance rate, treatment rate for hypertension among residents aged over 30, treatment rate for diabetes among residents aged over 30, annual healthcare utilization rate, and positive attitude rate toward overall safety levels.

The implementation of various interventions in Nam-gu through the project resulted in the subjective health status awareness rate increasing from 71.6% to 71.8% and the EQ-5D score rising from 0.982 to 0.985. All performance indicators of the targeted health determinants also showed improvement (Table 2). Notably, although the subjective health status awareness rate in the project area (Samho-dong) was 20.4% lower than that in the comparison area (Ok-dong) before the project (71.6% vs. 92.0%, respectively), Samho-dong outperformed Ok-dong by 4.8% after the project (71.8% vs. 67.0%). Thus, the health disparities within the region were reduced.

Table 2 Difference between pre and post for project intervention in Samho-dong, Nam-gu, Ulsan and Samdong-myeon and Changseon-myeon, Namhae-gun, Gyeongsangnam-do

Project intervention in Samho-dong, Nam-gu, Ulsan (2020–2022)
Indicator		Indicator definition	Pre	Post	Difference (post-pre)
Health outcomes (2)	Health level awareness rate	(People who responded that their subjective health level was “very good” or “good”/Number of respondents surveyed)×100	71.6%	71.8%	0.2% ↑
	Quality of Life Index (EQ-5D)	An indicator that synthesizes the descriptive system of five dimensions of health-related quality of life (exercise ability, self-management, daily activities, pain/discomfort, anxiety/depression)	0.982	0.985	0.003 ↑
Health decision factor (5)	Walking practice rate	(Number of people who walked at least 30 minutes a day, more than 5 days a week in the past week/Number of respondents surveyed)×100	47.8%	55.6%	7.8% ↑
	Treatment rate of people diagnosed with high blood pressure (≥30)	(Number of people currently receiving treatment for high blood pressure/Number of people aged 30 or older who have been diagnosed by a doctor)×100	90.4%	90.5%	0.1% ↑
	Cure rate for people diagnosed with diabetes (≥30)	(Number of people currently receiving treatment for diabetes/Number of people over 30 years old diagnosed by a doctor)×100	78.1%	83.8%	5.7% ↑
	Annual health facility utilization rate	(People who have used a public health center [health center], public health branch, or health clinic in the past year/Number of respondents surveyed)×100	8.2%	9.0%	0.8% ↑
	Overall safety level	(Number of people who responded positively about the overall safety level of our neighborhood [natural disasters, traffic accidents, agricultural accidents, crime]/Number of respondents surveyed)×100	87.0%	90.8%	3.8% ↑

Project intervention in Samdong-myeon and Changseon-myeon, Namhae-gun, Gyeongsangnam-do (2020–2022)
Indicator		Indicator definition	Pre	Post	Difference (post-pre)
Health outcomes (2)	Health level awareness rate	(People who responded that their subjective health level was “very good” or “good”/Number of respondents surveyed)×100	15.2%	20.6%	5.4% ↑
	Quality of Life Index (EQ-5D)	An indicator that synthesizes the descriptive system of five dimensions of health-related quality of life (exercise ability, self-management, daily activities, pain/discomfort, anxiety/depression)	0.775	0.832	0.057 ↑
Health decision factor (11)	Proportion of good physical activity performance	Percentage of physical activity performance (standing up from a chair 5 times) good	60%	84.4%	24.4% ↑
	Improving elderly health-related quality of life (physical and mental areas)	Among the seven areas of quality of life related to sarcopenia in the elderly, the physical and mental health area improved by more than 2 points.	2 points or more	5.3	3.3 ↑
	Elderly nutrition index improver fraction	Elderly nutrition index proportion of people in medium-low gradesa)	56.0%	33.3%	22.7% ↓
	Proportion of people maintaining high blood pressure and diabetes within normal range	Proportion of people maintaining high blood pressure in normal range	Over 90%	91.6%	1.6% ↑
		Proportion of people maintaining diabetes in normal range		87.0%	3.0% ↓
	Proportion of people taking regular medication for high blood pressure and diabetes	Proportion of people taking regular medication for high blood pressure	Over 90%	95.6%	5.6% ↑
		Proportion of people taking regular medication for diabetes		98.7%	8.7% ↑
	Excellent practice autonomy in nutrition and physical activity	Excellent nutrition practice rate (attendance rate of 50% or more)	Over 50%	39.5%	10.5% ↓
		Excellent physical activity practice rate (attendance rate of 50% or more)		58.1%	8.1% ↑
	Linkage performance rate with related organizations	Performance rate for those linked to related organizations such as medical institutions	Over 10%	21.3%	11.3% ↑
	Program completion rate	Completion rate among registered residents	Over 90%	90.8%	0.8% ↑

EQ-5D=Health Related Quality of Life. ^a)Elderly nutritional index medium-low grades criteria: index score falls within the 0–49.9% percentile..

2) Samdong-myeon and Changseon-myeon, Namhae-gun, Gyeongnam

Namhae-gun developed an integrated care intervention model for older adults (Figure 2). The project set two health outcome performance indicators: the “subjective health status awareness rate” and the “Health-Related Quality of Life Index (EQ-5D).” Additionally, 11 performance indicators were established for health determinants, including the percentage of older adults with good physical activity capability, improvement in the health-related quality of life (physical and mental domains) of older adults, percentage of those who improved their nutrition index, the rate of maintaining normal ranges of blood pressure and blood glucose levels, hypertension and diabetes medication adherence rate, nutritional and physical activity compliance rates, linkage with related institutions, and program completion rate.

The administration of various intervention projects in Namhae-gun resulted in the subjective health status awareness rate in the project areas (Samdong-myeon and Changseon-myeon) increasing from 15.2% at baseline to 20.6% post-project and the EQ-5D score improving from 0.775 to 0.832. Except for the rate of maintaining the normal range of blood glucose level and nutritional compliance rate, all health determinant indicators showed improvement (Table 2).

Notably, the subjective health status awareness rate, one of the health outcome performance indicators, in the project areas was 1.4% lower than in the comparison area (the entire Namhae-gun) at baseline (15.2% vs. 16.6%, respectively), but 1.5% higher after the project (20.6% vs. 19.1%). Regarding health-related quality of life, the baseline EQ-5D score in the project areas was 0.052 points lower than that of the comparison area (0.775 vs. 0.827, respectively). However, the score in these areas increased to 0.832 post-project, while the comparison area’s score was 0.852. Thus, the gap between the areas was reduced to 0.020 points, and health disparities within the region were reduced. After completing the project in 2022, Namhae-gun continued to expand and implement it in 2023, using funds raised and allocated for this purpose.

3) Yongho 3-dong, Nam-gu, Busan

The project in Nam-gu, Busan, is currently underway (2022–2024). In its inaugural year, a combination of quantitative and qualitative surveys was conducted to assess community health issues to establish a solid foundation for project implementation and accurately determine the health status within the project area. Based on the survey results, significant intervention efforts were launched in the following year. Additionally, a comprehensive survey was conducted to address the needs of solitary older citizens, as this group was identified as particularly vulnerable. This enabled the development and execution of targeted interventions in collaboration with the local community (Table 2).

4) Sangri-myeon and Maram-myeon, Goseong-gun, Gyeongnam

Goseong-gun, Gyeongnam, is actively implementing a project in 2023–2025 by conducting surveys and in-depth analyses to identify the causes of health disparities within the subregions. In the project’s inaugural year, baseline surveys were deployed to evaluate residents’ health levels, alongside quantitative surveys and a qualitative focus group interview aimed at clarifying the causes of interregional health disparities. Additionally, a series of initiatives, including the creation of a healthy village environment (establishing a village health council, conducting health leader training, developing walking paths, organizing walking contests, and operating health promotion booths) and development of preliminary intervention programs (walking clubs, visits to senior welfare centers) were implemented (Table 2).

3. Future Tasks for the Development of the Subregional Health Disparity Reduction Project in the Gyeongnam Region

Various dynamic subregional health disparity reduction projects have been implemented in the Gyeongnam region through multidimensional efforts including participatory projects tailored to vulnerable groups, disease management facilitated by connecting with local primary healthcare providers and the health management services of community health centers, and linkage with other entities such as administrative welfare centers. The commonalities of these projects include enhancing the health of residents within the project areas by integrating various healthcare resources centered around community health centers, adopting a multidimensional approach specifically tailored to the needs of the target population, and establishing health safety networks based on linkage systems for visiting care and welfare services. Despite these efforts, however, the 2022 Community Health Survey indicates that while there has been a general improvement in health status across the Gyeongnam region, regional disparities in health indicators persist [5].

To spread the effect of the subregional health disparity reduction efforts within the Gyeongnam region, in-depth evaluations of the outcomes of past projects and identification of highly effective project types for development as standard regional intervention models are crucial.

For the ongoing implementation of sustainable subregional health disparity reduction projects, it is essential to secure central policy support, including funding and human resources, as well as continuous capacity building among residents to safeguard continuous resident-led local activities centered around regional entities like village health committees. Moreover, fostering a framework for active opinion formation and communication concerning health initiatives is vital to empower residents to autonomously plan and execute necessary health activities. Efforts need to be focused on sustaining and developing collaborative activities among healthcare providers, welfare agencies, administrations, and residents. This approach aims to strengthen social networks within the village, ultimately fostering a more dynamic and integrated care system within the community.

The Subregional Health Disparity Reduction Project conducted in Nam-gu (Ulsan) and Namhae-gun (Gyeongnam) has led to the establishment of a standard model for regional health promotion and intervention projects aimed at reducing subregional health disparities (Figure 2). This project was implemented to generate scientific evidence for related efforts through the evaluation of intervention effectiveness and find clues for enhancing the health levels of vulnerable regions, thereby increasing regional interest in health issues.

This project revealed that enhancing health levels solely through individual healthcare services has inherent limitations in addressing health disparities within a region, and—given the aging population and the continuous rise in the prevalence of chronic diseases—the capacity to provide individual healthcare services faces significant constraints. Conclusively, a comprehensive regional-level approach is essential for improving individual health outcomes and tackling health inequalities, which, in turn, can mitigate health disparities across subregions.

Moving forward, the Regional Centers for Disease Control and Prevention will fortify their collaboration with local governments to ensure the ongoing implementation of subregional health disparity reduction projects. They will also serve as a vital link, organically linking with the central government’s health disparity reduction policies to maximize the effectiveness of these projects.

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Conceptualization: YWK. Data curation: YWK. Project administration: YWK. Resource: YWK. Writing – original draft: YWK. Writing – review & editing: YWK, SJP.