重庆主城基本公共卫生服务中老年人健康管理的现状、需求及对策研究

发布时间：2018-07-17 16:17

【摘要】：为了应对我国严峻的老龄化形势给医疗卫生服务带来的巨大压力,2009年我国启动基本公共卫生服务,明确将老年人健康管理纳入基本公共卫生服务内容,意在将老年人慢性病控制的关口“前移”,立足老年人健康维护的“上游”,发挥基层医疗机构卫生服务功能,改善老年人群的健康状况。重庆市基层医疗机构自2009年开展老年人健康管理服务以来,到目前为止尚未见对其进行系统的评价。为了进一步改进老年人健康管理,本研究采用多种研究方法(定性定量研究相结合),从卫生服务供方和需方客观地对基层医疗机构基本公共卫生服务框架下的老年人健康管理的现状及存在的问题进行评价,同时从需方和供方对老年人健康管理的需求进行了系统的研究,以期为重庆市老年人健康管理的循证决策提供科学依据。研究目的通过定量研究和定性研究相结合的方法,从供方(基层医疗机构)和需方(老年人)的角度了解重庆市主城地区老年人健康管理服务的现状及需求,并提出对策建议。研究方法1.采用分层随机抽样方法在重庆市主城地区随机抽取一个有代表性的区/县,然后将被抽取的区/县所辖的基层医疗机构分成城市的社区卫生服务中心和农村的乡镇卫生院,再将社区卫生服务中心和乡镇卫生院分成发展较好和较差的两类,最后从每类基层医疗机构中随机抽取2个(共抽取8个基层医疗机构)作为研究地点。2.定量研究:在8个社区采用完全随机抽样方法抽取402名≥60岁的在社区接受健康管理服务的老年人作为研究对象,通过问卷调查了解重庆市老年人群对健康管理的一般情况、饮食习惯、行为生活方式、患病状况以及对健康管理服务的知晓、利用、评价情况,对健康管理的需求。调查资料用Epidata3.1软件建立数据库,用SPSS17.0统计软件进行分析。对被调查者的人口学特征、患病情况、行为生活方式和饮食习惯等进行描述性分析,并用知晓率、利用率、满意率等指标描述老年人对基层医疗机构提供的老年人健康管理的知晓情况、利用情况以及满意度。采用卡方检验筛选老年人不良饮食行为生活方式的相关因素以及老年人利用和评价健康管理服务的相关因素,然后采用二分类logistic回归分析法分析相关因素。3.定性研究:1)专题小组讨论(FGD):采用滚雪球抽样方法,在每个社区组织2组(男女各一组),共16组由社区老年人参加的专题小组,主要了解老年人的健康状况、健康素养以及对社区健康管理服务知晓、利用、评价、存在问题及原因。2)个人深入访谈:采用目的抽样法对8个社区卫生服务机构分别负责老年人健康管理和慢性病管理的工作人员、公卫科科长、社区卫生服务中心主任进行个人深度访谈,共20人。了解老年人健康管理的服务模式、服务效果、软硬件条件、服务成本、存在的问题及影响因素等。资料分析:所有定性资料采用国际上普遍使用的框架分析方法(thematicframework)对资料进行整理和分析。结果1.重庆主城基层医疗机构老年人健康管理服务开展的现状1)所调查的社区卫生服务机构都按照《2013版国家基本公共卫生服务规范》实施了老年人健康管理服务。服务的对象是辖区内≥60岁的老年人,服务的内容有生活方式评估、体格检查与辅助检查、健康评估、健康指导等项目。老年人对健康管理的利用率比往年高,多数社区目前在70%-80%左右;少数社区在50%及以下。卫生服务提供者认为目前健康管理的效果不理想。2)老年人对健康管理服务的知晓情况。总体上对健康档案、体格检查与辅助检查和健康指导的知晓率较高;对健康教育的知晓率偏低;知晓的途径都是医生下社区或者电话、短信等通知。3)老年人对健康管理服务的利用情况。总体上对健康档案、体格检查与辅助检查和健康指导的利用率较高(均95%)。少数没有体检的原因主要有:一是认为没有必要;二是没有时间;三是不知晓;四是个别老年人的家人认为没有必要参加体检。对健康教育的利用率偏低(85%);没有利用宣传资料和宣传栏的原因主要有:一是眼睛不好,看不清楚;二是不识字;三是记忆力不好,就不愿看。没有利用健康讲座的原因主要有一是不知晓;二是没有时间;三是文化层次较高的老年人因为对健康知识比较了解,认为没有必要参加。4)老年人对健康管理服务项目的满意度都比较高,对提供健康管理服务的社区卫生服务机构的综合评价也较高,最满意的是方便程度(93.3%)和服务态度(92.8%);满意度偏低的是硬件条件(62.3%)、技术水平(58.3%)和价格(57.6%);满意度评价与年龄、文化程度、退休前职业、性别等因素有关。老年人对社区医疗机构的软硬件条件不满的原因主要有:一是药物不齐;二是设备不好;三是技术水平需要提高;四是有些村卫生室不能打针输液。5)老年人健康管理存在的困难及影响因素:(1)老年人健康意识缺乏;(2)老年人健康管理的项目缺乏吸引力;(3)开展老年人健康管理的人力不足,相关专业培训缺乏,物力和财力保障不够;(4)在开展工作的过程中,街道、居委会、城管、小区物管、上级医院等部门不支持;(5)绩效考核指标不科学。2.重庆主城老年人健康管理服务开展的需求评估1)老年人患病情况。患任意一种慢性病的占81.7%,至少患有两种慢性病的占48.8%,至少患有三种慢性病的占21.8%,没有患病的占12.7%;患病率从高到低依次为高血压(61.9%),糖尿病(28.4%),冠心病(10.0%)血脂异常(8.7%),慢性支气管炎(8.0%),骨质疏松(6.0%)等。2)老年人认为需要优先解决的健康问题:(1)增加个性化的体检项目;(2)具体的、有针对性的健康指导方案;(3)基层卫生服务机构的技术水平需要提高、设备需要改进、药物配备需要扩大;(4)村卫生室能开展治疗服务;(5)建健康档案和看病结合起来等。3)大多数老年人都有比较良好的饮食习惯和行为生活方式,但是仍然有部分老年人有经常吃肥肉、甜食、以荤食为主、口味偏咸、新鲜蔬菜摄入不足、晚餐吃得过饱、运动不足、吸烟、饮酒等不良饮食行为生活方式。不良饮食行为生活方式与年龄、性别、户口所在地、退休前职业、bmi指数以及是否患有高血压/糖尿病等因素有关。老年人普遍缺乏健康知识、健康意识不足,城乡差异明显。4)基层医疗机构可利用于老年人健康管理的卫生资源。一是希望基层医疗机构和社会保障、医疗保障等部门联合,通过社保认证、医保报销、办理特病等与老年人利用健康管理挂钩,来提高老年人健康管理的利用率。二是希望和上级医院在高血压/糖尿病病人的信息资源共享和技术支持等方面合作,从而提高慢性病人筛查的效率和提高老年居民对基层医疗机构的信任度。三是希望当地政府协调街道、居委会等部门参与宣传活动,在政策宣传方面达到事半功倍的效果。结论重庆主城基层医疗机构开展的老年人健康管理服务,得到了老年人的普遍欢迎和肯定,促进了他们健康水平的提高。但是,目前开展的健康管理服务还处于起步阶段,与国家规范的要求和老年人的现实需求还有较大的差距。老年人健康管理的质量不高;老年人的慢性病负担重,行为生活方式有待改进,健康素养亟待提高。基层医疗机构开展老年人健康管理还面临以下困难:(1)基层医疗机构能力不足;(2)全社会对老年人健康管理的认识不到位;(3)国家的投入力度需要加大;(4)老年人健康管理的顶层设计不足;(5)多部门协作的局面未形成等。根据目前老年人健康管理开展的现状以及需方和供方的需求,提出以下决策建议。1.政府加大对基层医疗机构的人力、物力、财力投入,加强老年人健康管理服务的顶层设计,加快老年人健康管理的信息化建设,在多部门合作中积极发挥主导作用。2.通过提高基层医疗机构的管理水平和打造专业的健康管理团队来提升老年人健康管理服务的能力。3.加大宣传普及力度,提高社会对老年人健康管理的认识;创新健康教育方式,提高老年人的健康素养,形成以预防为主的健康意识。4.树立“大卫生观”意识,发挥多部门合力,强调社会保障、医疗保障、上级医院、街道、居委会、城管等部门协作,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.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R197.1

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