【摘要】：為了應(yīng)對我國嚴(yán)峻的老齡化形勢給醫(yī)療衛(wèi)生服務(wù)帶來的巨大壓力,2009年我國啟動基本公共衛(wèi)生服務(wù),明確將老年人健康管理納入基本公共衛(wèi)生服務(wù)內(nèi)容,意在將老年人慢性病控制的關(guān)口“前移”,立足老年人健康維護(hù)的“上游”,發(fā)揮基層醫(yī)療機(jī)構(gòu)衛(wèi)生服務(wù)功能,改善老年人群的健康狀況。重慶市基層醫(yī)療機(jī)構(gòu)自2009年開展老年人健康管理服務(wù)以來,到目前為止尚未見對其進(jìn)行系統(tǒng)的評價。為了進(jìn)一步改進(jìn)老年人健康管理,本研究采用多種研究方法(定性定量研究相結(jié)合),從衛(wèi)生服務(wù)供方和需方客觀地對基層醫(yī)療機(jī)構(gòu)基本公共衛(wèi)生服務(wù)框架下的老年人健康管理的現(xiàn)狀及存在的問題進(jìn)行評價,同時從需方和供方對老年人健康管理的需求進(jìn)行了系統(tǒng)的研究,以期為重慶市老年人健康管理的循證決策提供科學(xué)依據(jù)。研究目的通過定量研究和定性研究相結(jié)合的方法,從供方(基層醫(yī)療機(jī)構(gòu))和需方(老年人)的角度了解重慶市主城地區(qū)老年人健康管理服務(wù)的現(xiàn)狀及需求,并提出對策建議。研究方法1.采用分層隨機(jī)抽樣方法在重慶市主城地區(qū)隨機(jī)抽取一個有代表性的區(qū)/縣,然后將被抽取的區(qū)/縣所轄的基層醫(yī)療機(jī)構(gòu)分成城市的社區(qū)衛(wèi)生服務(wù)中心和農(nóng)村的鄉(xiāng)鎮(zhèn)衛(wèi)生院,再將社區(qū)衛(wèi)生服務(wù)中心和鄉(xiāng)鎮(zhèn)衛(wèi)生院分成發(fā)展較好和較差的兩類,最后從每類基層醫(yī)療機(jī)構(gòu)中隨機(jī)抽取2個(共抽取8個基層醫(yī)療機(jī)構(gòu))作為研究地點(diǎn)。2.定量研究:在8個社區(qū)采用完全隨機(jī)抽樣方法抽取402名≥60歲的在社區(qū)接受健康管理服務(wù)的老年人作為研究對象,通過問卷調(diào)查了解重慶市老年人群對健康管理的一般情況、飲食習(xí)慣、行為生活方式、患病狀況以及對健康管理服務(wù)的知曉、利用、評價情況,對健康管理的需求。調(diào)查資料用Epidata3.1軟件建立數(shù)據(jù)庫,用SPSS17.0統(tǒng)計軟件進(jìn)行分析。對被調(diào)查者的人口學(xué)特征、患病情況、行為生活方式和飲食習(xí)慣等進(jìn)行描述性分析,并用知曉率、利用率、滿意率等指標(biāo)描述老年人對基層醫(yī)療機(jī)構(gòu)提供的老年人健康管理的知曉情況、利用情況以及滿意度。采用卡方檢驗(yàn)篩選老年人不良飲食行為生活方式的相關(guān)因素以及老年人利用和評價健康管理服務(wù)的相關(guān)因素,然后采用二分類logistic回歸分析法分析相關(guān)因素。3.定性研究:1)專題小組討論(FGD):采用滾雪球抽樣方法,在每個社區(qū)組織2組(男女各一組),共16組由社區(qū)老年人參加的專題小組,主要了解老年人的健康狀況、健康素養(yǎng)以及對社區(qū)健康管理服務(wù)知曉、利用、評價、存在問題及原因。2)個人深入訪談:采用目的抽樣法對8個社區(qū)衛(wèi)生服務(wù)機(jī)構(gòu)分別負(fù)責(zé)老年人健康管理和慢性病管理的工作人員、公衛(wèi)科科長、社區(qū)衛(wèi)生服務(wù)中心主任進(jìn)行個人深度訪談,共20人。了解老年人健康管理的服務(wù)模式、服務(wù)效果、軟硬件條件、服務(wù)成本、存在的問題及影響因素等。資料分析:所有定性資料采用國際上普遍使用的框架分析方法(thematicframework)對資料進(jìn)行整理和分析。結(jié)果1.重慶主城基層醫(yī)療機(jī)構(gòu)老年人健康管理服務(wù)開展的現(xiàn)狀1)所調(diào)查的社區(qū)衛(wèi)生服務(wù)機(jī)構(gòu)都按照《2013版國家基本公共衛(wèi)生服務(wù)規(guī)范》實(shí)施了老年人健康管理服務(wù)。服務(wù)的對象是轄區(qū)內(nèi)≥60歲的老年人,服務(wù)的內(nèi)容有生活方式評估、體格檢查與輔助檢查、健康評估、健康指導(dǎo)等項目。老年人對健康管理的利用率比往年高,多數(shù)社區(qū)目前在70%-80%左右;少數(shù)社區(qū)在50%及以下。衛(wèi)生服務(wù)提供者認(rèn)為目前健康管理的效果不理想。2)老年人對健康管理服務(wù)的知曉情況。總體上對健康檔案、體格檢查與輔助檢查和健康指導(dǎo)的知曉率較高;對健康教育的知曉率偏低;知曉的途徑都是醫(yī)生下社區(qū)或者電話、短信等通知。3)老年人對健康管理服務(wù)的利用情況�？傮w上對健康檔案、體格檢查與輔助檢查和健康指導(dǎo)的利用率較高(均95%)。少數(shù)沒有體檢的原因主要有:一是認(rèn)為沒有必要;二是沒有時間;三是不知曉;四是個別老年人的家人認(rèn)為沒有必要參加體檢。對健康教育的利用率偏低(85%);沒有利用宣傳資料和宣傳欄的原因主要有:一是眼睛不好,看不清楚;二是不識字;三是記憶力不好,就不愿看。沒有利用健康講座的原因主要有一是不知曉;二是沒有時間;三是文化層次較高的老年人因?yàn)閷】抵R比較了解,認(rèn)為沒有必要參加。4)老年人對健康管理服務(wù)項目的滿意度都比較高,對提供健康管理服務(wù)的社區(qū)衛(wèi)生服務(wù)機(jī)構(gòu)的綜合評價也較高,最滿意的是方便程度(93.3%)和服務(wù)態(tài)度(92.8%);滿意度偏低的是硬件條件(62.3%)、技術(shù)水平(58.3%)和價格(57.6%);滿意度評價與年齡、文化程度、退休前職業(yè)、性別等因素有關(guān)。老年人對社區(qū)醫(yī)療機(jī)構(gòu)的軟硬件條件不滿的原因主要有:一是藥物不齊;二是設(shè)備不好;三是技術(shù)水平需要提高;四是有些村衛(wèi)生室不能打針輸液。5)老年人健康管理存在的困難及影響因素:(1)老年人健康意識缺乏;(2)老年人健康管理的項目缺乏吸引力;(3)開展老年人健康管理的人力不足,相關(guān)專業(yè)培訓(xùn)缺乏,物力和財力保障不夠;(4)在開展工作的過程中,街道、居委會、城管、小區(qū)物管、上級醫(yī)院等部門不支持;(5)績效考核指標(biāo)不科學(xué)。2.重慶主城老年人健康管理服務(wù)開展的需求評估1)老年人患病情況�；既我庖环N慢性病的占81.7%,至少患有兩種慢性病的占48.8%,至少患有三種慢性病的占21.8%,沒有患病的占12.7%;患病率從高到低依次為高血壓(61.9%),糖尿病(28.4%),冠心病(10.0%)血脂異常(8.7%),慢性支氣管炎(8.0%),骨質(zhì)疏松(6.0%)等。2)老年人認(rèn)為需要優(yōu)先解決的健康問題:(1)增加個性化的體檢項目;(2)具體的、有針對性的健康指導(dǎo)方案;(3)基層衛(wèi)生服務(wù)機(jī)構(gòu)的技術(shù)水平需要提高、設(shè)備需要改進(jìn)、藥物配備需要擴(kuò)大;(4)村衛(wèi)生室能開展治療服務(wù);(5)建健康檔案和看病結(jié)合起來等。3)大多數(shù)老年人都有比較良好的飲食習(xí)慣和行為生活方式,但是仍然有部分老年人有經(jīng)常吃肥肉、甜食、以葷食為主、口味偏咸、新鮮蔬菜攝入不足、晚餐吃得過飽、運(yùn)動不足、吸煙、飲酒等不良飲食行為生活方式。不良飲食行為生活方式與年齡、性別、戶口所在地、退休前職業(yè)、bmi指數(shù)以及是否患有高血壓/糖尿病等因素有關(guān)。老年人普遍缺乏健康知識、健康意識不足,城鄉(xiāng)差異明顯。4)基層醫(yī)療機(jī)構(gòu)可利用于老年人健康管理的衛(wèi)生資源。一是希望基層醫(yī)療機(jī)構(gòu)和社會保障、醫(yī)療保障等部門聯(lián)合,通過社保認(rèn)證、醫(yī)保報銷、辦理特病等與老年人利用健康管理掛鉤,來提高老年人健康管理的利用率。二是希望和上級醫(yī)院在高血壓/糖尿病病人的信息資源共享和技術(shù)支持等方面合作,從而提高慢性病人篩查的效率和提高老年居民對基層醫(yī)療機(jī)構(gòu)的信任度。三是希望當(dāng)?shù)卣畢f(xié)調(diào)街道、居委會等部門參與宣傳活動,在政策宣傳方面達(dá)到事半功倍的效果。結(jié)論重慶主城基層醫(yī)療機(jī)構(gòu)開展的老年人健康管理服務(wù),得到了老年人的普遍歡迎和肯定,促進(jìn)了他們健康水平的提高。但是,目前開展的健康管理服務(wù)還處于起步階段,與國家規(guī)范的要求和老年人的現(xiàn)實(shí)需求還有較大的差距。老年人健康管理的質(zhì)量不高;老年人的慢性病負(fù)擔(dān)重,行為生活方式有待改進(jìn),健康素養(yǎng)亟待提高�；鶎俞t(yī)療機(jī)構(gòu)開展老年人健康管理還面臨以下困難:(1)基層醫(yī)療機(jī)構(gòu)能力不足;(2)全社會對老年人健康管理的認(rèn)識不到位;(3)國家的投入力度需要加大;(4)老年人健康管理的頂層設(shè)計不足;(5)多部門協(xié)作的局面未形成等。根據(jù)目前老年人健康管理開展的現(xiàn)狀以及需方和供方的需求,提出以下決策建議。1.政府加大對基層醫(yī)療機(jī)構(gòu)的人力、物力、財力投入,加強(qiáng)老年人健康管理服務(wù)的頂層設(shè)計,加快老年人健康管理的信息化建設(shè),在多部門合作中積極發(fā)揮主導(dǎo)作用。2.通過提高基層醫(yī)療機(jī)構(gòu)的管理水平和打造專業(yè)的健康管理團(tuán)隊來提升老年人健康管理服務(wù)的能力。3.加大宣傳普及力度,提高社會對老年人健康管理的認(rèn)識;創(chuàng)新健康教育方式,提高老年人的健康素養(yǎng),形成以預(yù)防為主的健康意識。4.樹立“大衛(wèi)生觀”意識,發(fā)揮多部門合力,強(qiáng)調(diào)社會保障、醫(yī)療保障、上級醫(yī)院、街道、居委會、城管等部門協(xié)作,共同提高健康管理水平。
[Abstract]:In order to cope with the severe pressure on medical and health services in China, in 2009, our country started the basic public health service, and clearly put the health management of the elderly into the basic public health service. It aims to "move forward" for the control of chronic diseases of the elderly, and based on the "upstream" of the health maintenance of the elderly. The health service function of the grass-roots medical institutions was used to improve the health status of the elderly. Since the health management service of the elderly in Chongqing was carried out in 2009, it has not been systematically evaluated since 2009. In order to further improve the health management of the elderly, a variety of research methods (qualitative and quantitative research) have been adopted in this study. To evaluate the status and problems of the health management of the elderly under the framework of basic public health service in basic medical institutions, and to make a systematic research on the needs of the elderly health management from the demand side and the supplier to the evidence of the evidence of the health management of the elderly in Chongqing. The objective of this study is to provide scientific basis for decision-making. Through the combination of quantitative and qualitative research, the present situation and demand of the elderly health management service in the main city of Chongqing are understood from the point of view of the supplier (grass-roots medical institutions) and the demand side (old people), and the countermeasures and suggestions are put forward. Method 1. the method of stratified random sampling is used in Chongqing city. In the main city, a representative district / county is randomly selected, then the grass-roots medical institutions under the jurisdiction of the district / county are divided into urban community health service centers and rural township health centers, and then the community health service centers and township hospitals are divided into two types of better and poorer development, and finally from each type of grass-roots medical institutions. 2 (a total of 8 primary medical institutions) were selected as the research site.2. quantitative study. In 8 communities, 402 elderly people aged more than 60 years of age were selected to receive health management services in 8 communities. Behavioral lifestyle, illness status and awareness of health management services, utilization, evaluation, and demand for health management. The survey data were built with Epidata3.1 software and analyzed with SPSS17.0 software. The demographic characteristics, illness, behavior, lifestyle and dietary habits of the respondents were described. This paper describes the awareness, utilization and satisfaction of the elderly health management of the elderly, using the awareness rate, utilization rate and satisfaction rate, and the related factors of using the chi square test to screen the unhealthy diet behavior of the elderly and the related factors of the elderly people using and evaluating the health management service. Then, the two classification logistic regression analysis was used to analyze the.3. qualitative study of related factors: 1) thematic group discussion (FGD): using snowball sampling method, 2 groups (men and women in each group) were organized in each community, and a total of 16 groups of elderly people participated in the community, mainly to solve the health status of the elderly, health literacy and community health management. Personal in-depth interviews with 8 community health service agencies responsible for the health management of the elderly and the management of chronic diseases, the chief of the public health department and the director of the community health service center were interviewed by the 8 community health service agencies, 20 people. Service mode, service effect, software and hardware condition, service cost, existing problems and influencing factors. Data analysis: all qualitative data are collated and analyzed by international general framework analysis method (thematicframework). Results 1. the health management service of the elderly in the primary city medical institutions in Chongqing is now carried out. 1) the community health service institutions investigated were all implemented the elderly health management service according to the <2013 national basic public health service specification. The target of the service was the aged people over 60 years old in the jurisdiction. The contents of the service were life style assessment, physical examination and auxiliary examination, health assessment, health guidance and other projects. The elderly were healthy. The utilization rate of management is higher than in previous years, most communities are now around 70%-80%; a small number of communities are 50% and below. Health service providers think that the effect of health management is not ideal.2) the awareness of health management services for the elderly. The awareness rate of health education was low; the ways to know all were the doctors' community or telephone, short message, etc..3) the use of health management services for the elderly. In general, the utilization rate of health records, physical examination and auxiliary examination and health guidance was higher (all 95%). Two is no time; three is not known; four is the family of individual elderly people think that there is no need to participate in physical examination. The utilization rate of health education is low (85%); the reasons for no use of publicity materials and publicity columns are mainly: first is bad eyes, not clear; two is illiterate; three is not good at memory. No health lectures are used. No health lectures are used. The main reasons are that one is not known; two is no time; three is the older people with higher cultural level, because of the knowledge of health knowledge, and think that there is no need to participate in the.4) the elderly are more satisfied with the health management services, and the comprehensive evaluation of the health service agencies providing health management services is also higher and most satisfactory. It is the convenience (93.3%) and the service attitude (92.8%); the low degree of satisfaction is the hardware condition (62.3%), the technical level (58.3%) and the price (57.6%); the satisfaction evaluation is related to the age, the education level, the pre retirement occupation, the sex and other factors. The reasons for the old people dissatisfied with the hardware and software conditions of the community medical institutions are mainly drug disintegration; two, The equipment is not good; three is the technical level need to be improved; four is the difficulty and influence factors of the health management of the elderly in some village clinics: (1) the lack of health awareness of the elderly; (2) the health management of the elderly is not attractive; (3) the lack of manpower for the health management of the elderly, the lack of related professional training and material resources. And financial security is not enough; (4) in the process of carrying out the work, the street, the neighborhood committee, the city management, the district management, the superior hospital and other departments do not support; (5) the performance evaluation index is not scientific.2. Chongqing main city old people health management service to carry out the demand assessment 1) the elderly disease situation. Any kind of chronic disease accounts for 81.7%, at least have two kinds of chronic diseases. The disease accounted for 48.8%, at least 21.8% of three chronic diseases, 12.7% without disease; the prevalence rate from high to low was hypertension (61.9%), diabetes (28.4%), coronary heart disease (10%) dyslipidemia (8.7%), chronic bronchitis (8%), and osteoporosis (6%).2) the elderly considered the need to solve the health problems: (1) increase the individualized body Inspection projects; (2) specific, targeted health guidance programs; (3) the technical level of the grass-roots health service institutions need to be improved, equipment needs to be improved, medical equipment needs to be expanded; (4) the village health rooms can carry out treatment services; (5) the construction of health files and medical care, etc..3) most elderly people have better eating habits and behavior. Life style, but there are still some elderly people who often eat fat, sweet food, meat and meat, taste partial, fresh vegetables intaking, supper full, lack of exercise, smoking, drinking and other unhealthy eating behavior lifestyle. Bad eating behavior lifestyle and age, sex, residence, pre retirement occupation, BMI index and is The basic medical institutions can be used for the health management of the elderly. First, the basic medical institutions and the social security, medical security and other departments, through social security certification, medical insurance reimbursement, management. Special diseases are associated with the use of health management for the elderly to improve the utilization of health management for the elderly. Two is to cooperate with higher hospitals in the sharing of information resources and technical support for hypertension / diabetes patients, so as to improve the efficiency of the screening of chronic patients and to improve the trust degree of the elderly residents to the grass-roots medical institutions. Three is the hope. The local government coordinates the street, the neighborhood committee and other departments to participate in the propaganda activities, which has achieved twice the result of half the effort in the policy propaganda. Conclusion the health management service of the elderly in the primary medical institutions in the main city of Chongqing has been widely welcomed and affirmed by the elderly, which has promoted the improvement of their health level. However, the health management has been carried out at present. The medical service is still in the initial stage, and there is a big gap between the requirements of the national standard and the actual needs of the elderly. The quality of the elderly health management is not high; the chronic disease burden of the elderly is heavy, the behavior life style needs to be improved and the health literacy needs to be improved. The following difficulties are also faced by the grass-roots medical institutions to carry out the health management of the elderly: (1) The capacity of basic medical institutions is insufficient; (2) the awareness of the health management of the elderly is not in place; (3) the investment of the country needs to be increased; (4) the top level of the health management of the elderly is insufficient; (5) the situation of multi sector cooperation is not formed. It is suggested that the government should increase the human, material and financial input to the grass-roots medical institutions, strengthen the top level design of the health management service for the elderly, speed up the information construction of the health management of the elderly, and play a leading role in the cooperation of the multiple departments, and.2. by improving the management level of the medical treatment institutions at the grass-roots level and building a professional health management. The team to improve the ability of the elderly health management service.3. increase publicity, improve the social awareness of the elderly health management, innovative health education methods, improve the health of the elderly, the formation of a health awareness.4. based on prevention to establish a "big health concept", play multi sector joint force, stress social security, medical treatment Ensure that the higher level hospitals, streets, neighborhood committees, urban management departments and other departments work together to improve the level of health management.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R197.1

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