基于Andersen行为模型的养老机构内老年人卫生服务项目利用的影响因素调查研究

Influencing Factors of Health Services Utilization among the Elderly in Elderly Care Institutions:a Study Using Andersen’s Behavior Model

背景当前养老机构内老年人患病率高,但对养老机构提供的卫生服务利用率低。明确养老机构内老年人对卫生服务项目利用的影响因素,有助于指导社区卫生服务中心与养老机构合作开展医养结合服务,改善养老机构内老年人卫生服务利用率,提高健康水平。目的研究养老机构内老年人卫生服务项目利用的影响因素,为社区卫生服务中心与养老机构合作开展医养结合服务提供决策依据。方法2017年9-12月,选取上海市浦东新区东明社区卫生服务中心所辖区域内的两家养老机构内老年人进行问卷调查。调查内容包括:个人基本信息、健康状况、经济条件、可利用的区域卫生服务资源及卫生服务利用情况。基于Andersen行为模型,分析养老机构内老年人卫生服务项目利用的影响因素,采用Logistic模型中自变量相对重要性的优势分析方法,计算倾向因素、使能因素和需求因素的调整R2值和相对重要性权重。结果共发放问卷368份,回收问卷353份,有效问卷344份,问卷有效回收率为93.5%。养老机构内老年人利用频率最高的3项卫生服务分别为体检(95.6%)、门诊(92.4%)和药事服务(83.4%)。多因素Logistic回归分析结果显示,性别、曾从事职业类型为养老机构内老年人体检利用情况的影响因素(P<0.05);入住养老机构时间、护理等级、两周内是否患病、养老机构为养老机构内老年人健康教育与咨询利用情况的影响因素(P<0.05);性别、朋友同事来养老机构探望频率、月收入、医疗保险类型为养老机构内老年人门诊利用情况的影响因素(P<0.05);医疗保险类型、养老机构为养老机构内老年人临床护理利用情况的影响因素(P<0.05);子女来养老机构探望频率、护理等级、两周内是否患病为养老机构内老年人急诊利用情况的影响因素(P<0.05);朋友同事来养老机构探望频率、两周内是否患病为养老机构内老年人转诊利用情况的影响因素(P<0.05);文化程度、半年内是否患慢性病、养老机构为养老机构内老年人药事服务利用情况的影响因素(P<0.05)。倾向因素主要影响体检服务,影响程度为67.3%;需求因素主要影响健康教育与咨询、急诊、转诊服务,影响程度分别为58.9%、71.7%和71.9%;使能因素主要影响门诊、临床护理、药事服务,影响程度分别为42.4%、65.3%和44.9%。结论养老机构内老年人的卫生服务利用主要集中于预防保健与常见病、慢性病诊疗服务。养老机构内老年人卫生服务项目利用的主要影响因素因服务内容的不同而存在差异,社区应根据养老机构内老年人的卫生服务项目利用决策特点为优化服务提供策略。

Background In elderly care institutions,the elderly people have a high prevalence of diseases but a low health services use rate.Identification of the influencing factors of health services use in this group,helps to guide the cooperation of community health centers (CHCs) and elderly care institutions in codelivering integrated medical and nursing care,and improve the health services use rate and health status in this population.Objective To explore the influencing factors for health services use in the elderly in elderly care institutions,providing a reference for decision making during the codelivery of integrated medical and nursing care by CHCs and elderly care institutions.Methods From September to December 2017, a survey was carried out in the elderly people in two elderly care institutions in the service area of Pudong New Area Dongming Community Health Center,Shanghai.A self-developed questionnaire was used in the survey,which is composed of basic personal conditions,health status,economic conditions,available local health resources and use of heath services.Influencing factors for health services use in the elderly were analyzed with the Andersen's behavior model.Dominance analysis approach was used to compare the relative importance of the independent variables in Logistic model.The adjusted R2 value and relative importance weight of predisposing,enabling and need factors were calculated.Results Among the 368 cases participating in the survey,353 handed in the questionnaires,and 344 of them returned responsive ones,obtaining a response rate of 93.5%.The most frequently used 3 services were physical examination (95.6%),outpatient services (92.4%),and pharmaceutical services(83.4%).Multivariate Logistic regression analysis showed that gender and types of occupation were associated with the utilization of physical examination (P<0.05).Admission time to elderly care institutions,level of nursing care,two-week morbidity,and accessible medical institution were associated with health education and counseling utilization (P<0.05).Gender, visiting frequency of friends and colleagues,monthly income and medical insurance type were associated with outpatient services utilization (P<0.05).Types of medical insurance and accessible medical institution were associated with clinical care (P<0.05).Visiting frequency of children,level of nursing care,and two-week morbidity were associated with emergency services utilization (P<0.05).Visiting frequency of friends and colleagues,and two-week morbidity were associated with referral services utilization (P<0.05).Education level,six-month prevalence of chronic diseases and accessible medical institution were associated with pharmaceutical services utilization (P<0.05).Predisposing factors were the main influencing factors for physical examination services utilization,contributing 67.3% of the total cumulative impacts.Need factors were the main influencing factors for health education and counseling utilization,emergency services utilization and referral services utilization,contributing 58.9%,71.7% and 71.9% of the total cumulative impacts,respectively.And enabling factors were the main influencing factors for the utilization of outpatient services,clinical care,and pharmaceutical services,contributing 42.4%,65.3% and 44.9% of the total cumulative impacts,respectively.Conclusion The commonly used services in the elderly in elderly care institutions are preventive health care,common and chronic disease diagnosis and treatment.The main influencing factors of the health care utilization vary according to the type of services.In view of this,community-based healthcare organizations should optimize the strategies of delivering services to this group according to their characteristics of decision-making for health care utilization.