【作者】 刘保国；

【导师】 孙晓杰；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2023， 硕士

【摘要】 研究背景我国面临日益严峻的老龄化趋势,空巢老人数量迅速增加,伴随着一系列老年健康问题的出现,特别是农村空巢老人患慢性病的比率仍然很高,其中原发性高血压在农村空巢老年群体中的发病率居首位。高血压的慢性进展、治愈难度大以及昂贵的治疗费用,给许多家庭带来了沉重的经济负担。与城市空巢老人相比,农村空巢老人的经济状况较为困难,对健康问题的认识较为薄弱,他们所面临的健康问题更加紧迫和显著。然而,由于经济能力有限等原因,农村空巢老年高血压患者的医疗需求仍然得不到充分满足。因此,改善农村空巢老年高血压患者的医疗服务利用至关重要,在当前国内提倡新型养老模式如“家庭养老”、“社会养老”、“互助养老”的背景下,学者们对“社会资本”的概念产生了广泛关注。研究社会资本对老年群体医疗服务的改善利用具有极其重要的意义。研究目的本研究旨在通过理论研究和实证分析,探讨我国农村空巢老年高血压患者(60岁及以上)医疗服务利用的现状,并分析不同层面社会资本因素对其医疗服务利用的影响,以社会资本为出发点,为改善农村空巢老年高血压患者的医疗服务利用情况提出科学依据和对策建议。研究方法本研究使用2021年6-7月在山东省菏泽、济南、威海进行的老年高血压患者生命质量横断面问卷调查数据。调查对象为农村空巢老年高血压患者,年龄在60岁及以上。经过数据提取、整理、剔除和合并等步骤,最终纳入有效样本数为835人。研究变量包括患者个人基本特征、社会资本信息以及医疗服务利用状况。在社会资本测量方面,使用个体层次的”资源生成器”量表来评估患者个体层次社会资本存量,并通过社会信任、互惠和互助来测量村庄层次社会资本指标。本研究对样本人群的社会人口学特征、社会资本状况及医疗服务利用状况进行了综合统计描述。采用单因素和多因素分析等方法,探究了影响60岁以上农村空巢老年高血压患者利用医疗服务的相关因素。此外,使用了两水平Logistic回归模型对农村空巢老年高血压患者医疗服务利用行为进行了深入分析。上述分析过程主要借助了 STATA 16.0软件进行。研究结果(1)采用“资源生成器”量表测量了农村老年高血压患者的个体社会资本,结果显示,个体总社会资本的平均得分为(18.66±4.13),整体处于中等偏上水平。对各维度得分归一化处理后,各维度得分从高到低依次为日常生活资源、困境应对资源、专家咨询资源、技能资源。在村庄社会资本层面,54.61%的患者村庄信任高,53.89%的患者村庄互惠高。(2)医疗服务利用方面,835名农村空巢老年高血压患者中,过去一年发生门诊服务利用的患者有390人,占46.71%;共139名患者过去一年发生住院服务利用,占16.65%;共78名患者发生应就诊未就诊的情况,占比9.34%;发生应住院未住院情况的患者有23名,占比2.63%。(3)单因素分析结果显示,拥有医疗保险、就医决策由配偶和他人做出、有慢性病共病、测血压频率高、自评健康状况差、日常生活资源少的患者门诊服务利用更多(P<0.05);有医疗保险、有最低生活保障、非每日外出、外出有难度、至最近医疗机构时间为6分钟及以上、就医资金来源子女储蓄或其他、有慢性病共病、自评健康状况差、生活满意度差、个体总社会资本低、日常生活资源少的患者住院服务利用更多(P<0.05);自评经济状况不是中等、与子女关系较差、BMI(Body Mass Index)正常、生活满意度较差、个体总社会资本低、日常生活资源更少、专家咨询资源更少、困境应对资源更少的患者更容易发生应就诊未就诊(P<0.05);女性、有最低生活保障、至最近医疗机构时间低于10分钟、测血压频率为每半月一次、个体总社会资本低、日常生活资源更少、专家咨询资源更少、困境应对资源更少的患者更容易发生应住院未住院(P<0.05)。(4)两水平Logit回归模型显示,在控制了混杂因素后,专家咨询资源(OR=1.192,P=0.005)对样本地区农村空巢老年高血压患者门诊服务利用存在正向影响,日常生活资源(OR=0.870,P=0.006)对患者门诊服务利用在负向影响;村庄互惠(OR=0.502,P=0.030)对患者住院服务利用存在正向影响,个体总社会资本(OR=0.941,P=0.024)、日常生活资源(OR=0.820,P=0.003)、村庄信任(OR=0.601,P=0.026)对患者住院服务利用存在负向影响;个体总社会资本(OR=0.936,P=0.014)、专家咨询资源(OR=0.799,P=0.015)越高患者发生应就诊未就诊的可能性越低。结论与建议研究结果显示,样本地区的农村空巢老年高血压患者社会资本整体处于较高的水平;医疗服务利用水平不高,应就诊未就诊和应住院未住院发生情况相对较少。在控制混杂因素后,日常生活资源越高,利用门诊服务利用、住院服务的概率越低,专家咨询资源越高,利用门诊服务、发生应就诊未就诊的概率越低,个体总社会资本越高,发生应就诊未就诊、利用住院服务的概率越低,村庄信任越高,利用住院服务的概率更低,村庄互惠越高,利用住院服务的概率更高。基于此,本文拟提出以下建议:(1)引导农村空巢老年高血压患者形成对社会资本的理性认知。基层医疗机构可向患者进行宣传教育,发挥社会资本关键维度的作用,使患者在需要医疗服务方面的帮助时,可以及时得到针对性帮助,医疗需求得到满足。(2)提升农村空巢老年高血压患者专家咨询资源,改善其医疗服务利用。通过建立健全专家咨询网络、提供专业咨询服务的培训和支持等方式,使患者能够便捷地获取专业的医疗咨询和建议;同时,为患者提供专业的医疗咨询服务,并定期进行培训和交流。(3)多层次丰富农村空巢老年高血压患者社会资本。社会舆论应鼓励农村空巢老年高血压患者在维护自身人际关系网、丰富个体层面社会资本的同时,积极与村民进行互惠、互助合作,提高患者之间以及患者与村民之间的相互支持和资源共享。更多还原

【Abstract】 Background The rapid growth of China’s aging population has brought attention to the issue of empty-nest elderly individuals,particularly in rural areas.Among this demographic,there is a significant prevalence of chronic diseases,with essential hypertension being the most common health problem.Rural empty-nest elderly individuals experience a significant burden of treatment due to the prolonged duration,low cure rate,and high treatment costs associated with their health conditions.In comparison to their urban counterparts,rural empty-nest elderly individuals often have limited financial resources and a lower level of health awareness,leading to more severe health issues.Despite an increasing demand for various medical services,their access to adequate healthcare remains limited due to economic constraints and other factors.Therefore,the improvement of medical service utilization among rural emptynest elderly hypertensive patients may be a crucial part of the development of healthy aging in my country.The global scholarly community has shown increasing interest in the concept of "social capital".Given the current emphasis on new pension models in China,it is crucial to explore the role of social capital and its embedded resources in enhancing the utilization of medical services among the elderly population.Objective This study combines theoretical research and empirical analysis to analyze the status quo of medical service utilization among rural empty-nest elderly hypertensive patients aged 60 and above and the influence of different levels of social capital factors on medical service utilization,based on the perspective of social capital,the scientific basis and countermeasures for improving the utilization of medical services for empty-nest elderly hypertensive patients in rural areas were put forward.Methods The data analyzed in this study came from a cross-sectional survey on the quality of life of elderly hypertensive patients conducted in 3 cities with different economic development levels in Shandong Province from June to July 2021.The research objects were selected rural empty-nest elderly hypertensive patients aged 60 and above who participated in the survey completely;through the process of data extraction,sorting,elimination,and merging,835 effective samples were finally included.The variables in this study encompass three main components:patient’s basic characteristics,patient’s social capital information,and patient’s medical service utilization status.The individual-level stock of social capital is measured using the"resource generator" scale,while hierarchical social capital indicators,such as social trust,reciprocity,and mutual assistance,are utilized to assess the patient’s social capital.In this study,the basic personal characteristics,social capital status and medical service utilization status of the sample population were described in general statistics.Univariate and multivariate analysis methods were used to analyze the influencing factors of whether the elderly used medical services at the individual level;a two-level Logit regression model was used to analyze the medical service utilization behavior of the elderly over 60 years old.Analysis,the above analysis was mainly carried out by STATA 16.0 software.Results(1)The individual-level social capital score is reported as(18.66±4.13),indicating an upper-middle level.Among the dimensions,domestic resource has the highest score,followed by problem-solving resources with difficulties.Expert consultation resources rank second,while personal skill resources have the lowest score.In terms of village-level social capital,54.61%of patients had high village-level trust,and 53.89%of patients had high village-level reciprocity.(2)Regarding medical service utilization,among the 835 rural empty-nest elderly hypertensive patients,390 individuals(46.71%)utilized outpatient services in the past year,while 139 individuals(16.65%)had inpatient service utilization during the same period;a total of 78 patients failed to see a doctor when they should see a doctor,accounting for 9.34%;there were 23 patients who should be hospitalized but were not hospitalized,accounting for 2.63%.(3)The results of univariate analysis showed that patients with medical insurance,medical decisions made by their spouses and others,chronic disease comorbidities,high blood pressure measurement frequency,poor self-rated health status,and few domestic resources used more outpatient services(P<0.05);patients have medical insurance,have minimum living security,do not go out every day,have difficulty going out,the time to the nearest medical institution is 6 minutes or more,the source of funds for medical treatment is children’s savings or other sources,have chronic diseases and comorbidities,self-assessed poor health,and life satisfaction Patients with poor medical degree,low individual total social capital,and few domestic resources utilized more inpatient services(P<0.05);patients whose self-rated economic status is not moderate,poor relationship with children,normal BMI,poor life satisfaction,less individual-level social capital,less domestic resource,few expert consultation resources,and less problem-solving resources are more likely to fail to seek medical attention.Seeing a doctor(P<0.05);Patients who are female,have minimum living allowances,take less than 10 minutes to the nearest medical institution,have blood pressure measurements every half a month,have less individual-level social capital,have few domestic resources,have few expert consultation resources,and have few problem-solving resources are more likely to develop Should be hospitalized but not hospitalized(P<0.05).(4)After controlling the confounding factors,the two-level Logit regression model showed that expert advice resources(OR=1.192,P=0.005)had a positive impact on the outpatient service utilization of empty-nest elderly hypertensive patients in the sample area.The domestic resource(OR=0.870,P=0.006)have a negative impact on the utilization of outpatient services;village-level reciprocity(OR=0.502,P=0.030)had a positive impact on patients’ inpatient service utilization,individuallevel social capital(OR=0.91,P=0.024),domestic resource(OR=0.820,P=0.003),village-level trust(OR=0.601,P=0.026).The higher the individual-level social capital(OR=0.936,P=0.014)and expert advice resources(OR=0.799,P=0.015),the lower the possibility of patients failing to seek medical treatment.Conclusion and Suggestion The results of this study show that the social capital status of rural empty-nest elderly hypertensive patients in the sample area is generally above the middle level;the level of utilization of medical services is not high,and there are relatively few cases of non-hospitalization and non-hospitalization.After controlling confounding factors,domestic resource positively affect the utilization of outpatient services and inpatient services,expert advice resources are positively affecting the utilization of outpatient services,and the should but not see a doctor,Individuals with higher overall social capital have a lower probability of seeking medical care without actually visiting a healthcare provider or utilizing hospital services,higher levels of trust within villages are associated with a lower probability of utilizing hospital services,conversely,higher levels of reciprocity within villages are associated with a higher probability of utilizing hospital services.Based on the findings,this study puts forward the following suggestions:(1)Guide rural empty-nest elderly hypertensive patients to develop a rational understanding of social capital.Grassroots healthcare institutions can carry out promotional education to highlight the key dimensions of social capital,ensuring that patients can receive targeted assistance and have their medical needs met when they require medical services.(2)Enhance expert advice resources for rural empty-nest elderly hypertensive patients to improve their utilization of medical services.This can be achieved by establishing a robust expert consultation network and providing training and support for professional consultation services.Patients should have convenient access to professional medical advice and recommendations,and healthcare providers should undergo regular training and exchange programs.(3)Enrich the social capital of rural empty-nest elderly hypertensive patients at multiple levels.Public opinion should encourage patients to maintain their social networks and enrich individual-level social capital while actively engaging in reciprocal cooperation and mutual assistance with villagers.This will foster mutual support and resource sharing among patients and between patients and villagers.更多还原