【作者】 刘永兵；

【导师】 姚华；

【作者基本信息】 新疆医科大学 ， 劳动卫生及环境卫生学， 2013， 博士

【摘要】 目的：新疆已于2010年整体迈进人口老龄化社会，60岁及以上老年人口以年均4.36%的速度增长。由于我国家庭结构核心化不断发展，使传统的家庭养老功能不断弱化，老年人选择老年公寓安度晚年是我国社会发展的一种趋势。同时，60～70%的老年人合并有慢性疾病，要求老年人在自我健康管理中承担更为重要的角色。目前国际上广泛认同健康教育与健康促进是改善老年人群健康水平的主要手段之一，并将健康素养的改善情况作为反映健康教育与健康促进行动效果的一个重要指标。本研究旨在深入了解养老机构老年人健康素养现状、相关影响因素以及健康素养与老年人自我护理能力、身心健康及社会状况的关系，并借助结构方程模型构建健康素养影响模式，为今后制定健康干预计划、科学进行老年人健康素养干预、建立干预效果评价体系提供依据，为新疆老年健康保健及健康促进工作打下坚实的基础。方法：采取整群抽样的办法。收集乌鲁木齐市、昌吉市、克拉玛依市、石河子市现有养老机构信息资料，共有养老机构44家，入住老年人4500余名，将符合纳入和排除标准的老年人做为研究对象，由调查员采用询问的方式获取信息。共获得合格问卷1396份，对养老机构老年人进行研究。资料采用EXCEL2000建立数据库进行数据录入，利用SPSS15.0统计软件、AMOS17.0完成数据分析。统计方法包括描述性统计分析、单因素方差分析、多元线性回归分析、Pearson相关分析、典型相关分析及结构方程模型。结果：1.养老机构老年人健康素养现状及影响因素：（1）养老机构老年人健康素养现状及影响因素分析：本研究显示，新疆养老机构老年人健康素养处于较低水平。健康素养总分以65～74岁年龄组最高，随着年龄的增高，健康素养有逐渐下降的趋势。男性高于女性。汉族高于少数民族。学历越高，健康素养越高，以大学及以上学历最高。随着家庭收入增多，健康素养增高。离异老年人健康素养最高，未婚最低。曾经从事职业层次越高，健康素养越高，其中单位管理者最高，专业技术人员次之，农民最低。老年人健康素养独立影响因素包括教育水平、族别、曾经从事职业、家庭收入、年龄、婚姻状况。（2）乌鲁木齐市、昌吉市、克拉玛依市（地方）养老机构老年人与石河子市（兵团）养老机构老年人相比：乌鲁木齐市、昌吉市、克拉玛依市（地方）养老机构老年人健康素养总得分为75.46±30.41，四个维度健康知识得分为34.30±18.34，健康信念为23.60±7.75，健康行为11.00±4.32，健康技能为7.41±5.32，与石河子市（兵团）养老机构老年人相比（健康素养总得分为70.17±22.83，四个维度健康知识为31.81±13.48，健康信念为22.52±6.65，健康行为9.35±3.61，健康技能为4.49±3.40），除健康知识、健康信念差异无统计学意义以外（P＞0.05），健康素养总得分、健康行为、健康技能均差异有统计学意义（P＜0.05）。（3）与医院有合作关系养老机构的老年人和与医院无合作关系养老机构的老年人相比：与医院有合作关系养老机构的老年人健康素养总得分为73.09±25.18，四个维度健康知识为32.58±14.35，健康信念为22.98±6.81，健康行为12.10±4.13，健康技能为6.67±3.52，和与医院无合作关系养老机构的老年人相比（健康素养总得分为71.61±28.74，四个维度健康知识为32.47±17.16，健康信念为22.78±7.49，健康行为9.59±3.81，健康技能为5.03±5.07），其中健康行为及健康技能差异有统计学意义（P＜0.05），而健康素养总分、健康知识、健康信念均差异无统计学意义（P＞0.05）。2.健康素养与养老机构老年人自我护理能力、身心健康及社会状况的关系。（1）养老机构老年人健康素养与自我护理能力的关系：养老机构老年人自我护理能力得分108.72±17.37，自我护理能力高水平者占43.48%，中等水平者占56.38%，低水平者占0.14%，自我护理能力以中等水平为主。由典型相关分析可知，健康素养与自我护理能力之间的相关系数达到0.457，主要表现在健康信念、健康行为与自护技能、自我概念相关性较大，呈正相关。（2）养老机构老年人健康素养与社会支持的关系：养老机构老年人社会支持总分为31.33±7.34，与国内常模相比处于较低水平（t=8.42，P＜0.001）。由典型相关分析可知，健康素养与社会支持的相关系数达到0.372，主要表现在健康信念、健康行为与主观支持、客观支持相关性较大，呈正相关。（3）养老机构老年人健康素养与健康状况的关系：养老机构老年人健康状况（包括身体健康得分为52.57±10.70，心理健康得分为52.20±8.19，日常生活活动能力得分为23.67±9.27）中，身体健康与心理健康总得分104.77±16.92，良好者占25.64%；中等者占71.20%；差者3.15%，说明养老机构老年人身体健康及心理健康大多数处于中等水平。52.29%的老年人存在日常生活功能损害，有不同程度的依赖。由典型相关分析可知，健康素养与健康状况之间的相关系数达到0.308，主要表现在健康信念、健康行为与身体健康、日常生活活动能力相关性较大。健康信念、健康行为与身体健康呈正相关，与日常生活活动能力呈负相关。3.应用结构方程模型构建健康素养对自我护理能力、身心健康及社会状况的影响模式：从路径分析结果可知，健康素养对自我护理能力的影响路径有一条，为直接效应，路径系数为0.263；健康素养对社会支持的影响路径有一条，为直接效应，路径系数为0.471；健康素养对健康状况的影响路径包括直接效应和间接效应，直接影响路径有一条，路径系数为0.074，间接影响路径有三条，路径系数之和为0.194，健康素养对健康状况影响路径总效应为0.268。可见健康素养对自我护理能力、社会支持、健康状况的影响是明显的，影响程度较大。其中健康素养对健康状况的影响路径较多，影响较大，间接效应比直接效应对健康状况的影响大。结论：1.新疆养老机构老年人健康素养处于较低水平。健康素养重点干预对象为女性、少数民族、文化程度低、兵团地区老年人，应促成更多养老机构与医院的合作关系，通过全方位、多部门合作，形成健康促进工作团队，提高老年人健康素养，满足老年人的健康需求，使老年人自己管理健康，实现健康老龄化。2.健康素养与养老机构老年人自我护理能力、身心健康及社会状况的关系密切，应将健康信念、健康行为干预做为养老机构老年人健康素养干预的重要内容和手段。3.健康素养对自我护理能力、身心健康及社会状况影响模式的结构方程模型拟合良好，符合理论假设。回归路径验证结果表明：所有影响路径都成立，与本研究的期望结果一致，该健康素养影响模式可应用于养老机构老年人健康教育及健康促进干预活动。通过制定相应的措施和方法，形成团队工作的方式，提高老年人的健康素养，调动老年人的主观能动性，促进自我护理，争取并利用尽可能多的社会支持，最终改善老年人健康状况，使身体健康、心理健康、日常生活活动能力不断好转，达到自我管理健康，提高生活质量的目的。更多还原

【Abstract】 Objective: Xinjiang has been entered the ageing society in2010, The elderly peoplewere2.33million,10.8%by the end of2011. The increasing nuclear families decreasethe capacity to care the elders, many elderly people will select nursing home to live intheir old age. At the same time, elderly people were social vulnerable groups,60～70%of them combined with various diseases, they were expected to assume a greater role inmaintaining their health and wellness. At present, health education and health promotionare viewed as the principal methods to improve health level in internationally, healthliteracy become an important indicator for judgment. Health literacy has been definedas“the degree to which individual have the capacity to obtain, process and understandbasic health information and services needed to make appropriate health decision”. Thepurpose of this study were to find out the status quo and influence factors of healthliteracy of elderly people in nursing home, the relations among health literacy andself-care agency, physical-mental health, social condition, to apply the structural equationmodel (SEM) to establish the influence modes of health literacy. To provide theevidences for intervention program and to improve self-care agency, physical and mentalhealth, social condition. Methods: A stratified cluster random sampling method wasselected. There are44nursing home,4500elderly people in Urumuqi, Changji, Karamay,Shihezi city. The investigator obtained the information from elderly people who met theinclusive and exclusive criteria through interview method. A total of1396questionnaireswere qualified and were studied. All data were analyzed by statistical analysis softwarepackage of SPSS (version15.0) and AMOS (Analysis of Moment Structures, version17.0), including descriptive analysis, single factor analysis, multiple linear regression,pearson correlation analysis, canonical correlation analysis and SEM analysis. Results:1. The status quo and influence factors of health literacy of elderly people in nursing home.(1) Analysis on the status quo and influence factors of health literacy of elderly people innursing home: The results showed that the health literacy of elderly people in nursinghome of Xinjiang were very low. The score of health literacy were highest in age from65to74, the higher the age were, the lower the health literacy were. Male were higher thanfemale. Han were higher than minority. The higher the education lever were, the higherthe health literacy were, the college and above were the highest. The higher thehousehold income were, the higher the health literacy were. In marital status, thedivorced elderly people were the highest, the unmarried were the lowest. The higher theformer profession were, the higher the health literacy were, the managers were thehighest, the professionals were secondly, the peasants were the lowest. The influencefactors of health literacy include education level, race, former profession, householdincome, age, marital status.(2) Comparation between local city and the XinjiangProduction and Construction Corps. The health literacy scores of elderly people innursing home of local city were75.46±30.41, the four dimensions such as healthknowledge were34.30±18.34, health attitudes were23.60±7.75, health behavior were11.00±4.32, health skills were7.41±5.32, to compared with the Xinjiang Productionand Construction Corps (the health literacy scores were70.17±22.83, the fourdimensioms such as health knowledge were31.81±13.48, health attitudes were22.52±6.65, health behavior were9.35±3.61, health skills were4.49±3.40), there werenot statistical significants in health knowledge, health attitudes (P＞0.05), and werestatistical significants in health literacy, health behavior and health skills (P＜0.05).(3)Comparation between cooperation with hospital and noncooperation with hospital: Thehealth literacy scores of elderly people in nursing home of the cooperation with hospitalwere73.09±25.18, the four dimensions such as health knowledge were32.58±14.35,health attitudes were22.98±6.81, health behavior were12.10±4.13, health skills were6.67±3.52, to compared with the noncooperation with hospital (the health literacy scoreswere71.61±28.74, the four dimensioms such as health knowledge were32.47±17.16,health attitudes were22.78±7.49, health behavior were9.59±3.81, health skills were5.03±5.07), there were statistical significants in health behavior, health skills (P＜0.05)and were not statistical significants in health literacy, health knowledge, health attitudes(P＞0.05).2. The relation among health literacy and self-care agency, physical-mentalhealth, social condition.(1) The relation between health literacy and self-care agency:The self-care agency scores were108.72±17.37, the high level were about43.48%, intermediate level were about56.38%, low level were about0.14%, The self-care agencygave priority to the intermediate level. Canonical correlation analysis showed thatcorrelation coefficient between health literacy and self-care agency were0.457. Thecorrelation were larger between health attitudes, health behavior and self-care skills,self-esteem.(2) The relation between health literacy and social support: The socialsupport scores were31.33±7.34, they were very low to compare with national norm(t=8.42, P＜0.001). Canonical correlation analysis showed that correlation coefficientbetween health literacy and social support were0.372. The correlation were largerbetween health attitudes, health behavior and subjective support, objective support.(3)The relation between health literacy and health status: The health status scores (physicalhealth were52.57±10.70, mental health were52.20±8.19, ADL were23.67±9.27): thetotal points of physical health and mental health were104.77±16.92, the high level wereabout25.64%, intermediate level were about71.20%, low level were about3.15%, thephysical health and mental health gave priority to the intermediate level. The functionallesion of activities of daily living in elderly people were about52.29%, they weredependent in different degrees. Canonical correlation analysis showed that correlationcoefficient between health literacy and health status were0.308. The correlation werelarger between health attitudes, health behavior and physical health, ADL. They werepositive correlation between health attitudes, health behavior and physical health, werenegative correlation between health attitudes, health behavior and ADL.3. To establishinfluence mode of health literacy to self-care agency, physical-mental health, socialcondition through SEM. The path analysis showed: there was a direct influence path fromhealth literacy to self-care agency, the path coefficient were0.263. there was a directinfluence path from health literacy to social support, the path coefficient were0.471.There were direct and indirect influence path from health literacy to health status: thepath coefficient were0.074of a direct influence path, the path coefficient were0.194ofthree indirect influence paths, the total effects were0.268. In a word, the influence werevery significant from health literacy to self-care agency, social support and health status.Among them, There were more influence paths from health literacy to health status, theindirect effects were larger than direct effect. Conclusion:1. The health literacy levelwere very low in elderly people of nursing home. The key intervention objects of healthliteracy are those elderly people who are female, minority, lower education level and theXinjiang Production and Construction Corps. If more nursing homes are cooperated withhospitals, and more work teams are formed to provide health education and health promotion, to improve health literacy and meet health requirement, more elderly peoplecan manage health by himself, the healthy aging will come true.2. There are closerelations among health literacy, self-care agency, physical and mental health, socialcondition, the emphases and contents of health literacy intervention should be focus onhealth attitudes, health behavior.3. The model fitting are fine of the SEM of healthliteracy influence mode, they are correspond with the threshold theory. The regressionpath analysis show that all the influence path are tenable. The health literacy influencemode can be used in the intervention works of health education and health promotion inelderly people of nursing home.更多还原