【作者】 刘丽娟；

【导师】 郭强；

【作者基本信息】 第二军医大学 ， 社会医学与卫生事业管理， 2008， 博士

【摘要】 随着生活和住房条件的改善,家庭结构的小型化,以及大量年轻人外出求学和工作,导致我国“空巢”老人数量逐渐增多。“空巢”老人作为我国社会变化过程中产生的弱势群体,他们的身心健康状况不容乐观。本研究拟通过对某山区农村“空巢”与非“空巢”老人健康与卫生服务利用的对比研究,评价该地区农村“空巢”老人的健康与卫生服务利用公平性,并深入分析影响“空巢”老人卫生服务利用的因素;通过对该地区乡镇卫生院的现况调查,找出该地区乡镇卫生院在“空巢”老人卫生服务中存在的不足;借鉴西方国家居家卫生服务实践,进一步探讨居家卫生服务对“空巢”老人的健康保障作用,在此基础上建立该地区农村“空巢“老人居家卫生服务模型。研究结果将对改善该地区农村“空巢”老人的健康状况、提高其卫生服务利用水平产生深远的影响,也将为全国范围内农村相应体系的建立提供借鉴。我们采用个人基本情况调查表、社会支持评定量表、自报健康状况与卫生服务利用情况调查表、36条目简明健康量表、UCLA孤独量表、老年抑郁量表、生活满意度指数Z、日常生活活动能力调查表对湖北省远安县550位“空巢”和630位非“空巢”老人进行问卷调查,包括社会人口经济学特征、参加医疗保险情况、健康相关行为、自报健康状况、慢性病患病情况、生命质量、孤独水平、抑郁水平、两周就诊情况和年住院情况、卫生服务需要未满足情况、卫生服务需要未满足原因、生活自理能力、日常生活活动能力和生活满意度等。与非“空巢”老人相比,“空巢”老人的月收入水平较低、与子女关系较差、社会支持水平较低、参加医疗保险的人所占比例较低、吸烟率较高、自报健康状况较差、慢性病患病率较高、生命质量生理和心理维度得分都较低、孤独和抑郁水平较高、两周就诊率较低、卫生服务需要未满足率较高、生活满意度较低。“空巢”老人的生活自理能力和日常生活活动能力受损者均占一定比例,阻碍其卫生服务利用的因素主要包括服务的可及性、社会态度、服务质量和费用四个方面。我们对湖北省远安县的6所乡镇卫生院的相关知情人进行问卷调查和当面访谈,了解这6所乡镇卫生院卫生服务的基本情况,包括各类人员的类别、性别和学历构成、近五年的日均门诊量和住院量、科室设置、服务内容等。结果显示这6所乡镇卫生院人力配置规模不均,其卫生人力总量高于2003年全国平均水平;卫生人员性别构成均衡;多数卫生人员学历水平偏低;卫技人员的专业结构相对合理,但是缺少精通老年医学的医生和护士;没有开通就医热线;病人不能通过电话联系到医生;很少为病人提供上门服务;没有开设心理咨询服务及疾病康复服务;从2002年——2006年日平均门诊量和住院量都逐年下降。该县乡镇卫生院如果不进行适当改革,不突出自己的优势和特色,不仅不利于“空巢”老人的健康保障,也不利于其自身的长远发展。通过专家研讨会和概念建模的方式,建立了“空巢”老人卫生服务的目标模型、乡镇卫生院卫生服务的问题模型和老年居家卫生服务模型。结果显示:“空巢”老人卫生服务的目标是实现“空巢”老人的健康老龄化和积极老龄化,途径是为他们提供连续的、全方位的、没有灰色带的、能够提高他们独立生活能力的综合性服务;乡镇卫生院在“空巢”老人卫生服务中存在的问题主要包括卫生工作人员的态度、工作程序和内容、资源三个方面;老年居家卫生服务模型主要包括四个微观系统领域:自我管理支持、决策支持、递送系统设计和临床信息系统,服务内容包括初级卫生保健服务和社会服务两部分,服务方式为上门服务,充分利用乡镇的资源和政策,注重医患间的生产性交互,对于提高老年卫生服务质量很有帮助。这些结果提示,与非“空巢”老人相比,“空巢”老人存在着健康与卫生服务利用的相对不公平性,而卫生服务可及性差是阻碍其卫生服务利用的原因之一,相对于乡镇卫生院,居家卫生服务对于提高“空巢”老人卫生服务可及性、提高其独立生活能力、改善其生活质量具有很强的针对性。更多还原

【Abstract】 Life and housing condition improved, family structure miniaturized, and a lot of yong man studing and working outside, the number of empty nest elders in our country is increasing. The empty nest elders, as the weak population in the progress of social changing, their physical and mental health was not optimistic. According the survey of the health and health care utilization between the empty nest and not empty nest elders in the rural area of a mountainous county, to estimate the equity of health and health care utilization of the empty nest elders, and to furtherly analyze the factors influencing the health care utilization of the empty nest elders. Investigating the current conditions of the Township Hospitals in the area, to find their deficiencies in serving the the empty nest elders. Using western contries’ practice in home health care for reference, to further discuss the function of home health care in serving the empty nest elders, and to build the home health care modle serving the empty nest elders in the area. The study will be benefit to improve the rural empty nest elders’ health, increase their health care utilization. It will also provide reference for the home health care system building in the rural area of the whole country.A set of questionnaires, including general information questionnaire, Social Support Rate Scale, self report health and health care utilization questionnaire, 6-Item Short-Form Health Survey, UCLA Loneliness Scale, Geriatric Depression Scale, Life satisfaction Index Z and activities of daily living questionnaire, were sent to a randomized sample of 550 empty nest elders and 630 not empty nest elders in Yuan’an County, Hubei Provence. We investigated their social, demographic and economic characters, insurance status, health related behaviors, self report health, chronic health conditions, quality of life, loneliness, depression, two-week visits and one-year hospital admissions, unmet health care needs and the reasons, self-care ability, ability of daily life and life satisfaction, et al.. Compared with the not empty nest elders, the empty nest elders showed lower income, worse relationships with children, less social support, lower insurance coverage, higher prevalence of smoking consumption, worse self report health, higher prevalence of chronic diseases, lower physical and mental scores from SF-36, higher loneliness and depression level, lower two-week visit rate, higher health care need unmet rate and lower life satisfaction. There were quite a proportion of empty nest elders without self-care ability and ability of daily life. Among the empty nest old persons with unmet health care, the barriers fell into four groups: access, social attitudes, services, and cost. Questionaire investigation and interview were carried out among the people knowing the inside story in six Township Hospitals of Yuan’an County, Hubei Provence. The general information, including the classification, gender and education constitution ratio of all persons, daily outpatient and inpatient visits in the recent five years, section office setting and service, was investigated. The results showed that the human resource sizes in the six Township Hospitals were not equal; the total human resource was higher than the countrywide mean level in 2003; the gender constitution ratio of the health care staff was balanced; majority of the health care staff had lower education; the specialty structure of health technical staff was relatively rational; there was no doctors and nurses mastering geratology; and there was no health hotline, so patients can not contact with doctors by phone; the Township Hospitals seldomely provided home services; there was no psychology consulting and rehabilitation services; the daily outpatient and inpatient visits from 2002 to 2006 were decreacing year by year. Unless there was reform, and advantage and character of theirselves was emphasized in the Township Hospitals, it will not benefit the health of the empty nest elders and its own development.Using workshop and conceptual modeling methods, it was built that the goal model in care of empty nest elders, health care problem model of the Township Hospitals and home health care model for elders. The results showed that, the goal in care of empty nest elders, realizing their health and active aging, will come true through total, continuous, no grey-zone comprehensive services which increase the empty nest elders’ independency; the problems in care of the empty nest elders of the Township Hospitals were categorised into three main themes: attitudes among staff, processes of care and resources for care; home health care model for elders mainly included four microsystem domains: self-management support, decision support, delivery system design and clinical information system; the services included primary health care service and social service, which were provided in the patients’ home; at the same time, to improve the quality of health care, it was essential to fully utilize the resources and policies in the town and attach importance to the productive interactions between practice team and patients.The results suggested that compared with the not empty nest elders, the empty nest elders were unequal in health and health care utilization; the inaccessibility to health care was one of the barriers; compared with Township Hospitals, home health care can do better in improving the empty nest elders’ accessibility to health care, increasing their independent living ability and improving their quality of life.更多还原