【作者】 王斌；

【导师】 柴国荣；

【作者基本信息】 兰州大学 ， 公共管理·应急管理， 2023， 博士

【摘要】 气候变化被认为是“21世纪全球最大的健康威胁”。在中国,气候变化更加明显,其对公众健康的危害持续增强,间接导致医疗服务和社会福利负担不断加重。作为一个负责任的发展中国家,应对气候变化及相关环境健康风险对中国尤为重要和紧迫。鉴于此,本文运用系统文献回顾、调查研究和数据建模等多种研究方法,针对气候变化背景下公众面临的环境健康风险,从风险感知、风险分析和风险应对展开研究。第一,从普通民众和医疗卫生专业人员的双重视角切入,通过调查访谈,分析了普通民众和医疗卫生专业人员对气候变化及环境温度健康风险的感知情况。研究发现:(1)普通民众的健康风险感知水平较低,严重偏离了现实。他们的风险感知表现为“不关注、不了解,低估潜在的健康损害,也不知如何更有效地控制或避免风险”。相较于城镇居民,农村居民遭受的健康损害更大,但风险感知水平却更低。(2)医疗卫生专业人员认为气候变化及相关健康风险已经成为一个重要的公共问题,对公众健康、医疗卫生系统和社会经济的威胁都很大。其中,环境温度对公共健康的影响最广泛、最显著。(3)基层(社区和乡村)医疗卫生人员对相关风险理解相当有限,限制了风险应对能力。(4)目前相关风险的经验和证据不足,亟需关于常见重大疾病、脆弱人群和社会经济的经验证据。第二,根据风险感知的研究发现和医疗卫生专家的建议,以环境温度和心血管疾病入院为例,把环境温度作为致险因素,把心血管疾病入院视为一种健康风险,住院所产生的医疗资源占用和医疗费用支出作为风险引发的社会经济影响。利用天水和张掖2012～2015年间的气象和住院数据,使用DLNM建模分析估计了公众面临的环境健康风险,及其造成的社会和经济影响。研究发现:(1)环境温度变化与人群心血管疾病入院风险之间存在“U”型关系;且风险存在滞后性,例如,在天水低温事件发生后的第7天人群入院风险达到最大值;(2)健康风险导致了巨大的入院治疗、医疗服务压力和直接经济负担。例如,在张掖,健康风险引发了13.4%的入院治疗,造成了14.8%的医疗资源占用和7.6%的医疗费用支出。(3)相较于医疗费用支出中的医保支付部分,极端温度对个人支付部分的影响更强,造成的个人经济负担更大。例如,在张掖极低温度(-15°C)下,个人支付费用的增速是医保的2倍,可归因于极端温度的个人支付费用是医保支付费用的2倍。(4)风险更小的非极端温度却造成了更多的风险后果。第三,回归气候变化的宏观背景,基于风险感知和风险分析发现的经验证据,从风险预警、风险沟通和风险处置三方面提出应对相关健康风险的策略。(1)风险预警:在现有高温预警试点经验的基础上,以地市为单位,建立以健康为导向的气象健康风险预警系统,并辅以实时信息监测系统和数据管理中心。(2)风险沟通:以公众为中心,设计通俗易懂的风险沟通内容,选择公众喜闻乐见的沟通渠道,采取潜移默化的沟通方式。(3)风险处置:加强政府健康干预,减少居民有害暴露;基于“暴露—反应”关系,优化医疗资源调度,增强医疗系统韧性;把气候影响纳入医疗保障制度,降低群众就医负担;增加培训和教育,让基层医疗卫生工作者充分理解和掌握相关风险知识,在风险沟通和风险处置的一线发挥更大作用;践行“双碳战略”,积极参与应对气候变化全球治理,减缓气候变化,改善环境;建立合作制度,共同应对气候变化及相关健康风险。本研究的主要边际贡献有:第一,为应急管理和危机应对提供了有限经验证据,有助于我国应对风险社会的多元复杂风险。第二,增加了环境温度对人群健康、医疗服务和社会负担影响的经验证据,拓展了气候变化与健康研究领域。第三,研究发现可为气候变化公共健康风险应对,医疗资源优化配置,政策行动“成本—收益”分析,以及医疗保障制度改革提供支持。第四,将环境因素与间接健康结局直接关联,使用DLNM估计滞后效应的处理,拓宽了分析环境健康风险的思路。本研究的主要创新包括:内容上,研究了同一风险的双重维度,即主观风险感知和客观风险分析;研究了一个更加细微的场景——住院治疗场景,而且分析了直接和间接风险后果。方法上,使用DLNM模型,既估计了时点风险,又估计了时段(累积)风险,还描述了一段时间内的风险变化趋势;考虑到医疗资源的稀缺性和排他性,使用总住院床日测量医疗资源。结论上,与城镇居民相比,农村居民对气候变化相关健康风险的感知水平更低;相较于医疗费用支出中的医保支付部分,极端温度对个人支付部分的影响更强,造成的个人经济负担更多。本研究成果可助力我国应对气候变化及相关健康风险,消减相关健康威胁,改善和保护人民健康,为“推进健康中国建设”和建成“中国式现代化”尽绵薄之力。更多还原

【Abstract】 Climate change is considered the"greatest global health threat of the 21st century".In China,climate change is even more apparent,and its impact on public health continues to increase,indirectly leading to an increasing burden on medical services and social welfare.As a responsible developing country,addressing climate change and related environmental health risks is particularly important and urgent for China.Because of this,this paper uses various research methods such as systematic literature review,survey interviews,and data modeling to investigate the environmental health risks faced by the public in the context of climate change in terms of risk perception,risk analysis and risk response.First,this paper analyzed the perceived health risks of climate change and environmental temperature of the general public and health professionals through survey interviews,starting from the dual perspectives of the general public and health professionals.The study found that:(1)the general public’s health risk perceptions were low and seriously deviated from reality.Their risk perceptions were"not concerned,not aware,underestimated potential health damage,and did not know how to control or avoid risks more effectively."Compared with urban residents,rural residents suffer more health damage but have lower risk perception.(2)Health care professionals believe climate change and associated health risks have become an important public issue with significant threats to public health,health care systems,society,and the economy.Among them,ambient temperature has the broadest and most significant impact on public health.(3)The understanding of associated risks among primary health care workers is limited,limiting the ability to respond to risks.(4)Current experience and evidence on related risks in the region are insufficient,and empirical evidence on common major diseases,vulnerable populations,and socioeconomics are urgently needed.Second,based on the findings of risk perception studies and recommendations from health care experts,this paper selects ambient temperature and cardiovascular disease admissions as case studies,considers ambient temperature as a risk-causing factor,cardiovascular disease admissions as a health risk,and health care resource occupancy and health care expenditure resulting from hospitalization as risk-induced social and economic impacts.This paper uses meteorological and hospitalization data from Tianshui and Zhangye between 2012 and 2015 to estimate the environmental health risks faced by the public and their resulting social and economic impacts using DLNM modeling analysis.It was found that(1)there is a"U"shaped relationship between ambient temperature changes and the risk of cardiovascular disease admissions in the population,with a lag in risk.For example,in Tianshui,the risk of hospital admission reached a maximum on the 7th day after the low temperature event;(2)the health risk resulted in significant hospital admissions,health care pressure,and direct economic burden.For example,in Zhangye,health risks caused 13.4%of hospital admissions,resulting in 14.8%of health care resource utilization and 7.6%of health care expenditure.(3)Compared to health insurance payments in medical cost expenditures,extreme temperatures substantially impact personal payment costs and cause more personal financial burdens.For example,in Zhangye,the rate of increase in individual payment costs at extreme cold temperatures(-15°C)was twice as high as that attributable to Medicare.(4)Less risky non-extreme temperatures resulted in more severe risk consequences.Third,we return to the macro context of climate change and propose strategies to respond to related health risks:risk early warning,risk communication,and risk disposal,based on empirical evidence from risk perception and risk analysis.(1)Risk early warning:Based on the existing pilot experience of high temperature early warning,a health-oriented meteorological health risk early warning system,supplemented by a real-time information monitoring system and a data management center,will be established on a municipal basis.(2)Risk communication:Focusing on the public,risk communication content should be designed to be easy to understand;communication channels should be chosen to be popular with the public;and communication methods should be subtle.(3)Risk management:The government should strengthen health interventions to reduce harmful exposures of the population;Optimize the dispatch of medical resources and enhance the resilience of the medical system based on the"exposure-response"relationship;Climate impacts should be included in the medical security policy to reduce the public’s burden of medical expenses;Increase training and education so that primary health care workers can fully understand and master the relevant risk knowledge and play a more significant role in the front line of risk communication and risk management.The"two-carbon"strategy should be implemented to mitigate climate change and improve the environment;Establish a cooperative system to respond to climate change and related health risks jointly.The main marginal contributions of this study are:first,it provides limited experience and evidence for emergency management and crisis response,which helps our country adapt to the multiple and complex risks of a risk society.Second,it adds to the empirical evidence on the effects of ambient temperature on population health,health care delivery,and social burden,expanding the field of climate change and health research.Third,the findings can support the response to public health risks of climate change,the optimal allocation of health care resources,the"cost-benefit"analysis of policy actions,and the reform of the health care insurance system.Fourth,the direct association of environmental factors with indirect health outcomes and the use of DLNM to estimate lagged effects broadens the thinking on environmental health risk analysis.The main innovations of this study are as follows:in content,a dual dimension of the same risk,i.e.,subjective perceived risk and objective real risk,is studied;a more nuanced scenario,the hospitalization scenario,is studied,and both direct and indirect risk consequences are analyzed.In methodology,a DLNM model was used to estimate both point-in-time and time-period(cumulative)risk and to describe risk trends over time;total hospital bed days were used to measure health care resources,considering the scarcity and exclusivity of health care resources.In conclusion,rural residents have lower perceived health risks related to climate change than urban residents.The impact of temperature extremes on the individual payment component is stronger and causes more personal financial burden than the health insurance payment component of medical expenses.The research results can help China respond to climate change and related health risks,abate related health threats,improve and protect people’s health,and contribute to"promoting the building of a healthy China"and"Chinese-type modernization."更多还原