上海市某社区老龄化人群健康管理模式的探索

Study on health management model among elder population in a community of Shanghai

目的了解老龄化人群健康风险特点,采取综合性干预措施,探索老年人群健康管理模式。方法于2012年5和6月对上海市青浦区大新街社区60岁以上473名常住老人开展健康危险因素和主要慢性病(高血压、糖尿病、脑卒中、肿瘤)现患调查,并采取综合干预,2年后对该人群健康知识知晓率、健康行为形成率及4种慢病的管理率、控制率和死亡率作效果评估。结果老年男女在身高、体重、腰围、体质指数(BMI)和高血糖及吸烟危险因素方面差异有统计学意义(P<0.05)。干预两年后目标人群对健康知识知晓率由14.30%提高到64.29%,健康行为形成率由25.00%提高到66.68%;4种慢性病的管理率、控制率及死亡率干预效果明显(均P<0.05)。结论针对大新街社区老龄化人群存在的健康风险特点,采取的综合干预措施能促进老年人健康知识知晓率、健康行为形成率及4大慢病管理率、控制率的提高,降低疾病风险。

[Objective]To understand the characteristics of health risks in elder population, take comprehensive intervention measures, and study the health management model among elder population.[Metbods]The prevalence survey about major health risk factors and main chronic diseases（hypertension, diabetes, stroke and cancer） was performed among 473 elder people over 60 years old from Daxinjie Community of Qingpu District of Shanghai in May and June 2012. After two years of comprehensive intervention, the awareness rate of health knowledge, the formation rate of health behavior, as well as the management rate, control rate and fatality rate of four chronic diseases were analyzed and evaluated. [Results]There were significant differences in height, weight, waist circumference, body mass index （BMI）, hyperglyeaemia and smoking risk factors between men and women （P〈0.05）. After two years, the awareness rate of health knowledge increased from 14.30% to 64.29%, the formation rate of health behavior increased from 25.00% to 66.68%, and the management rate, control rate and fatality rate of four chronic diseases improved significantly （all P〈0.05）.[Conclusion]The comprehensive intervention measures based on the characteristics of health risks in elder population can improve the awareness rate of health knowledge and the formation rate of health behavior, increase the management rate and control rate of four chronic diseases, and reduce the risk of diseases.