湖南某县农村留守老年人生活质量与卫生服务利用研究
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摘要
研究背景
随着我国工业化、城镇化进程的加快,人口流动特别是农村人口向城市以及经济发达地区流动已经成为不可逆转之势,也是我国经济发展和社会转型的必然,农村留守已经成为一个普遍的现象。农村留守老人虽然可能得到外出打工、经商等子女经济上的资助,但由于随着年龄的增长,老年人的健康状况和各项生理功能逐渐下降,加上子女不在身边,缺乏亲情的慰籍,生活上得不到关怀,体力上得不到的帮助,有些甚至还要承担抚养、照料、教育孙代的责任,耕种子女外出后留下的责任田,从而形成了一个具有特殊需要和问题的老年群体；长期留守,除了导致留守老年人身心健康的影响外,还可以引起一系列的社会问题,最基本的问题如老年人的生命安全、经济供养、生活照顾、医疗保障、精神慰籍等；较深层次的社会问题也逐渐凸显,如农村养老制度和机制的建立,国家对农村老年人问题的经济承受能力,社会的稳定、青年人对老龄化社会的责任感,和谐社会的构建等。农村留守老年人作为我国经济发展和社会变迁过程中产生的弱势群体,农村留守老人成为我国经济发展和人口老龄化进程中不可忽视的重要问题之一,改善他们的健康状况、提高他们的生活质量和卫生服务利用水平是社会医学和卫生事业管理研究领域的一项重要的课题,对于构建社会主义和谐社会、实现新农村建设的目标具有重要的现实意义。在我国研究探索新一轮医药卫生体制改革之时,为了进一步完善我国农村医疗卫生服务体系和医疗保障制度,研究农村留守老年人的医疗卫生服务利用具有一定的现实意义和价值。
农村留守老人日渐引起了学术界的关注。现有的研究表明：①对农村留守老人的研究,国内学者主要集中在对农村留守老人的成因、生活质量、生活满意度、生活照料、老年人的居住、社会互助机制、子女外出后对老人的供养、面临的困难和问题以及家庭关系等；②现有的研究主要是从人口学和社会学的角度进行,研究方法主要以定性研究为主。但是,对于农村留守老人的定义,目前学术界还没有给出一个规范的可操作性的定义；即使有个别学者对农村留守老人的生活质量进行了研究,但是并不系统、全面,研究结果主要也还停留于对其健康状况的描述,缺乏对影响农村留守老人健康因素的深入分析；③对农村留守老人卫生服务利用的研究还未见报道。
研究目的
本研究的目标是通过对农村留守老人的一般特征、健康状况、生活质量评价及影响因素、健康与卫生服务利用的评价及影响因素的研究,为提高农村留守老年人生活质量、建立农村留守老人养老机制、提高卫生服务利用率、讨论解决农村留守老人健康问题的提出措施和建议,并为政府和社会解决此类问题提供理论基础,为探索农村卫生体制改革提供科学依据。
研究目的：
1.描述农村留守老人的一般特征；
2.定量评价农村留守老人的生活质量,分析影响农村留守老人生活质量的主要因素；
3.定量评价农村留守老人的健康与卫生服务利用状况,分析影响农村留守老人健康与卫生服务利用的主要因素；
4.提出改善农村留守老人健康状况的政策建议。
研究方法
本研究将农村留守老人尝试定义为：年龄在60岁以上,有健存子(媳)女(婿),且所有子(媳)女(婿)外出至本乡镇外6个月以上,子(媳)女(婿)外出后不能履行正常的照料义务,因种种原因不能随子女一起居住而留守在原户籍地生活的农村老年人。
1.研究现场与样本
(1)研究现场
本研究的研究现场选在湖南省衡阳县。衡阳县是湖南省88各县(县级市)之一,隶属于湖南省第二大城市衡阳市。衡阳县现辖26个乡镇,893个村。2007年年末人口111.47万,是衡阳市第二个人口大县。该县现有农业人口80.38万,2007年外出务工农村劳动力16.37万,是典型的农业大县。衡阳县人口总数在湖南省88个县(县级市)中处于第七位左右,人均国民生产总值处于湖南省各县(县级市)的中位,农民人均纯收入处于中上水平。在对农村留守老人的研究中,选择衡阳县具有一定的代表性。
(2)研究样本
采用分层、整群、随机抽样方法,首先根据上一年度农民人年均纯收入将衡阳县的26个乡镇分为经济状况好、中、差三个层次,从每层中各选择1个乡镇为研究现场,再从每个乡镇的所有行政村中各随机抽取3个村,以9个行政村的所有符合条件的老年人作为研究样本。
2.研究的内容与研究工具：
(1)老年人的一般人口学资料：采用自制的基本情况调查表,内容包括性别、年龄、婚姻状况、受教育程度、经济状况、经济来源、生活习惯、居住状况、子女状况等；
(2)健康状况与医疗卫生服务情况：参考全国卫生服务调查的有关指标自制调查表,主要指标包括慢性病患病率、两周患病率、两周就诊率、两周患者未就诊率、住院率、未住院率；
(3)健康相关生命质量：采用中文版SF-36 v2量表(the version 2 of the SF-36 health survey);
(4)日常生活能力：采用日常生活能力量表(Activities of Daily Living Scale, ADL);
(5)负性生活事件：使用肖林等制订的老年人生活事件量表(Life Events Scale for the Elderly, LESE)；
(6)睡眠质量：采用匹兹堡睡眠质量指数量表(PSQI)。
3.资料收集方法
由于受农村老年人文化程度的影响,本研究采取面对面访谈法,由调查员根据调查表内容逐条询问,老年人根据自身实际情况作答,调查员进行记录。
4.质量控制
本研究通过预调查、对调查员的统一培训、选择可靠的向导、制定质量控制表、双人数据录入等措施对调查质量进行控制。通过对调查员的一致性、各量表的重测信度评价,考量问卷的信度。
5.资料分析方法
采用EpiData 3.0建立数据库,用SPSS 13.0建立数据库并进行统计学分析,取检验水准(α)为0.05。运用描述性分析法、比较分析法、Pearson相关分析、Ordinal回归分析法、logistic逐步回归分析法对调查资料进行分析。
结果
资料收集于2009年2月10日至5月28日完成。调查的9个村共有1198名60岁及以上老年人,符合条件的有1126人,实际访谈到的有1042人,应答率为92.54%,有效样本1040人,资料的有效率99.82%,因研究需要,剔除无健存子女研究对象13人,进入分析的老年人共有1027人。
1.农村留守老人的一般情况
(1)样本中24.83%的老年人符合本研究“留守老年人”的定义。
(2)农村老年人子女外出情况
根据研究的定义,在1027名研究对象中,有部分子女外出的老年人占58.23%,所有子女全部外出的老年人占24.83%,没有子女外出的老年人占16.94%。
样本人群子女外出至外省占大部分,为70.5%；外出从事打工者占84.5%；外出时间超过三年者占91.42%；外出子女0.5-1年回家探亲一次者占40.8%,1-2年回家探亲一次者占33.4%。
(3)农村留守老人一般特征
1027名老年人中留守老年人255名,非留守老人772名。留守老人中男性占64.70%,女性占35.30%。
留守老年人与非留守老年人一般情况比较：留守老人年龄小；男性比例高；控制年龄因素以后,60-69岁组和70-79岁组配偶健在的比例高、60-69岁组和70-79岁组受教育的程度高；控制性别、年龄因素以后,自杀意念发生率高(P<0.05)；与孙辈居住的比例高；留守老人经济来源主要是自己、医疗费主要由自己支付,非留守老人经济主要来源于子女、医疗费主要由子女支付；患病时,留守老人自己照顾自己的比例高于非留守老人,由配偶照顾的比例和子女照顾的比例都要低于非留守老人(P<0.05)。其他如户籍、民族、自评经济状况、喝酒情况、吸烟、睡眠情况等无差别(P>0.05)。
两组老年人躯体生活自理(PSMS)、工具性日常生活能力(IADL)、总量表(ADL)得分经比较有统计学意义(P<0.05),非留守老人得分高于留守老人。留守老年人发生率排在前五位的生活事件分别为“子女长期离家”(96.86%)、“患有慢性疾病”(78.43%)、“家庭经济困难”(33.73%)、“本人住院治疗”(27.45%)、“家庭成员住院治疗”(27.06%)；非留守老年人发生率排在前五位的生活事件分别为“患有慢性疾病”(82.90%)、“子女长期离家”(73.96%)、“家庭经济困难”(39.77%)、“配偶死亡”(33.68%)、“本人住院治疗”(29.66%)。两组老年人负性生活刺激量比较无差别(P>0.05)。
2.农村留守老人生活质量
(1)留守对农村老年人生活质量的影响
分别以农村老年人的生理健康和心理健康为应变量,以留守等因素作为自变量,进行单因素和多因素ordinal分析回归分析显示,留守降低了农村老年人心理健康水平(P<0.05)。
(2)农村留守老人生活质量影响因素的单因素分析
①一般情况：性别、年龄、户口、教育水平、职业、经济状况、医疗保险、喝酒、娱乐休闲、自杀等10个因素是生理健康的影响因素(P<0.05)；经济状况是心理健康的影响因素(P<0.05)。
②两周内是否患病：两周内没患病的留守老在生理功能(PF)、生理职能(RP)、躯体疼痛(BP)、社会功能(SF)、情感职能(RE)、精神健康(MH)、总体健康总体自评(GH)个7维度及生理健康得分高比两周内患病的留守老人(P<0.05)。
③ADL：日常生活功能正常的留守老人在生理功能(PF)、生理职能(RP)、躯体疼痛(BP)、社会功能(SF)、情感职能(RE)、精神健康(MH)、总体健康总体自评(GH)个7维度及生理健康得分高于日常生活功能障碍的留守老人(P<0.05)。
④负性生活事件：生活刺激量小组的留守老人在生理功能(PF)、生理职能(RP)、躯体疼痛(BP)、社会功能(SF)、情感职能(RE)、精神健康(MH)、总体健康总体自评(GH)个7维度及生理健康和心理健康得分高于生活刺激量大组(P<0.05)。
⑤睡眠质量：睡眠质量好的留守老人在生理功能(PF)、生理职能(RP)、躯体疼痛(BP)、社会功能(SF)、情感职能(RE)、总体健康总体自评(GH)6个维度及生理健康、心理健康得分高于睡眠质量差的留守老人(P<0.05)
(3)多因素分析
采用Ordinal逐步回归分析显示：①性别、自评经济状况、吸烟、慢性病种数、两周患病情况、日常生活能力是留守老人生理健康的影响因素；②性别、自评经济状况、慢性病种数、两周患病情况、负性生活事件刺激量是留守老人心理健康的影响因素。生理健康和心理健康Ordinal逐步回归方程分别为(性别X1,自评经济状况X7、吸烟X10、慢性病种数X15、两周内是否患病X16、日常生活能力X17、负性生活事件刺激量X18)：Logt1=-10.535+1.688X1+1.221X7+0.985X7+0.887X10+1.850X15+1.271X 16+2.923X17 Logit2=-7.425+1.688X1+1.221X7+0.985X7+0.887X10+1.850X15+1.271X1 6+2.923X17; Logit1=21.300+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18 Zogit2=24.306+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18
3.农村留守老人就医行为及健康状况
(1)农村老年人就医医疗机构的选择
①门诊在村卫生室或个体诊所、卫生院的占70%以上。②留守老人35.4%在卫生院住院,40.0%在县级医院住院,24.6%在市级以上医院住院；非留守老人43.7%在卫生院住院,26.5%在县级医院住院,29.8%在市级以上医院住院。
(2)两周患病率与慢性病患病率
留守老人与非留守老人两周患病率分别为56.86%和65.28%,控制性别和年龄因素以后,两组老年人两周内患病率差异无统计学意义(P>0.05)。
留守老人与非留守老人的慢性病患病率分别为63.92%和65.67%,两组老年人慢性病患病率差异无统计学意义(P>0.05)。
4.留守老人健康卫生服务利用
(1)卫生服务利用的状况
①留守老人和非留守老人两周就诊率分别为14.90%和15.80%,两组老年人两周就诊率差异无统计学意义(P>0.05)。②留守老人、非留守老人两周患者未就诊率分别为73.79%和75.79%。留守老人与非留守老人排前三位未就诊原因依次是经济困难、自认为病情轻、自己有药品。③住院率：留守老人、非留守老人一年内住院率分别为16.86%和15.93%。④未住院率及原因：留守老人、非留守老人未住院率分别为48.19%和53.93%。留守老人与非留守老人排前三位未住院原因依次是经济困难、没人陪、自认为病情轻。
(2)健康及卫生服务利用影响因素的单因素分析
①性别、户籍、受教育程度、职业、经济来源、经济状况、自杀意念、有无患慢性病、负性生活刺激量、睡眠质量10个因素对留守老人两周患病率有影响；②年龄、婚姻状况、受教育程度、经济状况、自杀意念、有无患慢性病、自评健康状况、两周内有无患病、一年内有无住院9个因素对留守老人两周就诊率有影响；③慢性病患病率：性别、喝酒、ADL、负性生活事件刺激量、睡眠质量5个因素对留守老人慢性病患病率有影响；④年龄、婚姻状况、受教育程度、经济状况、医疗保险、有无患慢性病、自评健康状况、ADL、负性生活刺激量5个因素对一年内住院率有影响。
(3)健康及卫生服务利用的多因素分析
logistic逐步回归分析显示,职业、自评经济状况、有无慢性病为两周患病率的影响因素；年龄、有无慢性病为两周就诊率的影响因素；喝酒、负性生活事件刺激量、睡眠质量为慢性病患病率影响因素；婚姻状况、医疗保险、自评健康状况、ADL为一年住院率的影响因素。
结论
1.衡阳县农村老年人的留守率为24.83%。
2.留守降低了农村老年人的心理健康和生理健康水平。
3.留守并没有改善农村老年人的经济供养状况,而是导致农村家庭结构发生了改变,出现了以隔代家庭为主的家庭结构模式,加重了农村老年人的农业劳动,造成了子女照料的缺失等问题。
4.影响农村留守老人生理健康的因素有：性别、自评经济状况、吸烟、慢性病种数、两周患病情况、日常生活能力；影响心理健康的因素有：性别、自评经济状况、慢性病种数、两周患病情况、负性生活事件刺激量。
5.衡阳县农村留守老人慢性病患病率和两周患病率高于2008年全国农村老年人平均水平,两周就诊率与全国农村老年人基本持平。
6.职业、自评经济状况、有无慢性病是农村留守老人两周患病率的影响因素；年龄、有无慢性病为两周就诊率的影响因素；喝酒、负性生活事件刺激量、睡眠质量为慢性病患病率影响因素；婚姻状况、医疗保险、自评健康状况、ADL为一年住院率影响因素。
本研究的价值与创新
在我国经济与社会发展处于转型时期,在医药卫生体制改革之时,对农村留守老人的一般情况、·生活质量、健康状况、和卫生服务利用加以研究,揭示这个农村特殊人群的特点,反映其存在的问题,希望引起社会和政府对他们的关注和关心,在农村养老政策、农村卫生政策制定之时要充分考虑社会弱势群体的现状和需求,切实做到社会的公平与和谐。
本研究通过对衡阳县农村老年人子女状况的调查,以及留守给农村老年人带来的影响,并对农村留守老人的概念加以梳理和辨析,给出农村留守老人的概念,以便于学术界在对农村留守老人的研究提供参考。首次应用中文版SF-36 V2量表对农村老年人的生活质量进行评价,为该量表的推广应用提供依据,并对农村留守老人质量的影响因素进行分析。对农村留守老人的医疗服务利用及影响因素进行全面的分析。
Background
With the accelerated industrialization and urbanization of our country, the population movement, especially that rural population who migrates to the urban areas or economically developed areas has become irreversible. And it is also an inevitable phenomenon for our country's economic development and social transformation. Therefore, the left-behind population has become a common phenomenon. Although the elder left-behind can get some financial support from their children who has gone out for work, their health condition and physiological function are decreasing when the time past, and can not get a concern in nearby, lacking the comfort of kinship and the physical help. Some even still need to undertake the responsibility to take after and educate the offspring, or cultivate responsible farmlands which were left behind by their going out families. Therefore they become a population with special needs and problems. Long-term being left behind could bring psychological or physical health affects on the elder, as well as series of social problems. For example, the most essential problems are safety, economic support, daily care, medical care, spiritual comfort and so on. Deeper levels of social problems showed gradually as well, such as the establishment for rural pension system, financial capacity for the rural elder of our country, social stability, sense of responsibility of the young for the aging society, the establishment of harmonious society and so on. During the process of economic development and social changes, the elder left-behind becomes one of the important problems that can't be ignored in the process of our country's economic development and population aging. To improve the quality of their life, to better use of health service are the impressing problems in the field of social medicine and health service management, which would bring important practical significance for building a socialist harmonious society and realizes the aim of building new countryside. Hence, to study on the medical and health services utilization of the elder left-behind could bring practical significance and value for the improvement of the rural health service system and medical security system. The elder left-behind becomes the focus of the academia. The previous. studies had showed that①Most of the previous national scholars have been focused on causes of left behind problems, life quality, life satisfaction, life care, living condition, Social Solidarity mechanism, support, difficulties, problems,family relationships of the elder when their children going out, and so on;②The previous researches were mainly discussed the problem from the demographic and sociological aspects and most were the qualitative researches. However, no operational definition has been given by the current academia to the elder left behind. Though several researches have studied the life quality of the elder left behind, they were not systematical and comprehensively. The findings also mainly remained at the description of their health condition, lacking of in-depth analysis of health factors affecting the elderly staying in rural areas.③Studies on the use of health services for the elder left-behind population has not been reported.
Objectives
Via studying the general characteristics, health status, life quality and putative influencing factors, health and health care utilization and putative influencing factors among the elder left-behind population, we aims at giving advise and suggestion on improving the life quality of the elder left-behind population, establishing their pension system, increasing utilization of health services, discussing and solving their health problem. We also could give the theoretical basis for solving such problems to the government and the communities, and scientific basis for exploring health system reform in the rural areas as well.
1. Describe the general characteristics of the elder left-behind popultaion.
2. Quantitatively evaluate the life quality among the elder left-behind population and analyze the main influence factors.
3. Quantitatively evaluate health and health service utilization among the elder left-behind population and analyze the main influence factors.
4. Give suggestions on the health policy for the improvement of health conditions of the elder left-behind population.
Methods
The study attempted to define " Elder left-behind " as the rural elderly who cannot live with their family members for a variety of reasons, over 60 years of age, having surviving children (including daughter-in-law and son-in-law)who went out to the outside of the town for more than 6 months and cannot carry out the duty of maintenance.
1.Study area and Study population
(1)Study area
The study area is in Hengyang County of Hunan province. Hengyang is one of the 88 counties (county-level cities), belonging to the second largest city-Hengyang City which has 26 towns and 893 villages. At the end of 2007, it is the second most populous city of Hengyang City with a population of 1,114,700. It is a typical agricultural county with 803 800 agricultural population and163 700 migrant workers. In the study of the elder left behind, with the population ranking at the seventh and the per-capita GDP being in the middle level among 88 counties of Hunan Province, the per-capita net income of farmers being in the upper level, Hengyang County could be a representative sample,.
(2) Study population
Using multi-stage stratified cluster sampling, Firstly we divided the 26 townships into three layers according to the economic level (good、Medium and poor).Then one township was selected from each level and three villages were randomly selected from every township. Finally, all qualified old people of nine villages were selected as study population.
2.Research Content and Instrument
(1) General demographic data:Demographic variables were collected using self-made basic situation questionnaire. The contents involves gender, age, marital status, educational level, economic status, source of income, living habits, living conditions and child status etc al.
(2)Health Status and Medical Service:We made the situation questionnaire with indices including prevalence of chronic diseases, two-week prevalence, two-week consultation rate, two-week non-consultation rate, hospitalization rate,non-hospitalization rate.
(3) QOL:The quality of Life was collected using the version 2 of the SF-36 health survey.
(4) Activity of Daily Living:Activities of Daily Living Scale was used.
(5)Negative Life Events:Life Events Scale for the Elderly which was made by XiaoLin etc.
(6)Sleep Quality:PSQI was used to measure sleep quality.
3.Data Collection
Owing to the education level of the old, the face to face interview was adopted. The investigator asked the contents of the questionnaire one by one and recorded the results according to the answer of interviewees.
4.Quality Control
The quality of research was controlled by adopting piolt investigation, trained investigators,selecting credible guider,using quality control table,double data entry etc al. The reliability was measured by using the Consistency of investigator,test-retest reliability.
5.Data Analysis
EpiData 3.0 was adopted to establish data-base. SPSS 13.0 was used in all analyses. The data was analyzed by using descriptive analysis, comparative analysis, Pearson correlation analysis, Ordinal regression, Logistic progressive regression analyses. And the level of significance is 0.05.
Results
Data has been collected during February 10,2009 and May 28,2009. In the nine villages, there were 1198 elderly people aged 60 years and older, of which 1126 were qualified as our target population. Finally 1042 were investigated, the response rate was 92.54%. Except two persons, all the 1040 had completed information. For research,13 were eliminated because of having no surviving child.
1.The general Characteristics of Rural Remained Elderly
(1)24.83%of the total sample accorded with the definition of "Elder left behind".
(2)Imgration Situation of the children
Based on the definition, in the 1027 objects, there is 58.23% population having some of children going out and 24.83%having all of the children going out, left only 16.94%having no children going out for work.
The five most prevalent situations were "Going out to other provinces" (70.5%), "going out for work" (84.5%), "going out for more than three years (91.42%), "Back home once every 0.5-1 years" (40.8%)and "back home once every 1-2years"(33.4%).
(3) The general Characteristics of Rural Remained Elderly
In the 1027 objects,255 were the elder left-behind, in which male accounted for 64.70%.
The general comparison between the elder left-behind and the elder not left-behind:the elder left-behind population were younger, more likely to be male; After controlling the age factors,60-69 age group and the 70-79 age group had higher proportion of surviving spouses, and 60-69 age group and the 70-79 age group had higher level of education; Controlling for both gender and age, remained elderly had higher incidence of suicidal ideation and higher proportion of living with grandchildren (P<0.05); Among the elder left-behind group, the daily expenses and medical fees are more likely to be paid by their own,while among the elder not left-behind group, the daily expenses and medical fees are more likely to be paid by their children; When being sick, the elder left-behind population had higher proportion of taking care of themselves than the elder not left-behind population and had lower proportion of nursing by their children (P<0.05).The situations did not differ significantly in terms of household registration, nation, self-rating economic status, drinking, smoking, sleeping.
The elder left-behind group had significantly higher scores in PSMS, IADL, ADL (P< 0.05). The five most prevalent life events for the elder left-behind population were " children for long-term immigration' (96.86%), "suffering chronic disease" (78.43%), "family financial difficulties" (33.73%), "self-hospitalization" (27.45%), "family member hospitalization" (27.06%). The five most prevalent life events for the elder not left-behind were " suffering chronic disease " (82.90%), "children for long-term immigration" (73.96%), "family financial difficulties"(39.77%)," loss of spouse"(33.68%), " self-hospitalization" (29.66%). The stimulus quantity of negative life events did not differ significantly between the two groups (P> 0.05)
2.The life quality of rural remained elderly
(1)The effects of "left-behind" on rural elder
Regarding Rural physical and psychological health as dependent variables, "left-behind" as independent variables, univariate and multivariate analysis of ordinal regression analysis showed that "left-behind" decreased psychological health condition (P<0.05).
(2)Univariate analysis
①General condition:Gender, age, registered permanent residence, education level, occupation, economic status, medical insurance, drinking, amusement and suicide were associated with physical health; Economic status were associated with psychological health.
②two-week prevalence:The elder left-behind who were not sick in past two weeks had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, psychological health, general health (P< 0.05)
③ADL:The elder left-behind who had normal activity of daily living had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, mental health, general health (P< 0.05).
④negative life events:The elder left-behind who had low stimulus quantity of negative life events had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, mental health, general health (P< 0.05)
⑤leep quality:The elder left-behind who had good sleep quality had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, general health (P< 0.05)
(3)Multivariate Analysis
The Ordinal Stepwise Regression show:①Gender, self-rating economic status, smoking, quantity of chronic disease, two-week prevalence, activity of daily living were the influencing factors of physical function. Gender self-rating economic status, quantity of chronic disease,two-week prevalence, stimulus quantity of negative life events were the influencing factors for psychological health. The Ordinal Stepwise Regression equation were (GenderX1, self-rating economic status X7、smoking X10、quantity of chronic disease X15 two-week prevalenceX16、activity of daily livingX17、stimulus quantity of negative life events X18): Logitl=-10.535+1.688Xl+1.221X7+0.985X7+0.887X10+1.850X15+1.2 71X16+2.923X17 Logit2=-7.425+1.688X1+1.221X7+0.985X7+0.887X10+1.850X15+1.27 1X16+2.923X17; Logitl=21.300+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18 Logit2=24.306+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18
In the village health clinics or private clinics, hospitals accounted for more than 70%.②35.4%of elderly people staying in hospitals hospital, 40.0%in the county hospital,24.6%more than in the municipal hospital; 43.7%of non-Aging hospitalized in hospitals,26.5%in the county hospital,29.8%in municipal above hospital.
3.Health seeking behavior and health status
(l)Health seeking behavior of rural elderly
①70%of population chose village health clinics, private clinics or rural public health centre.②35.4%of the elder left-behind hospitalized in rural public health centre,40.0%in county hospital, and 24.6%in Municipal level and above hospital; 43.7%of elder not left-behind hospitalized in rural public health centre,26.5%in county hospital and 29.8%in Municipal level and above hospital.
(2)Two-week prevalence and chronic disease prevalence
The two-week prevalence of the elder left-behind was 56.86%, lower than these of elder not left-behind (65.28%). But after controlling for gender and age, there was no significant differences between those two groups (P>0.05)
The chronic disease prevalence of the elder left-behind was 63.92%,lower than these of elder not left-behind (65.28%). But there was no significant differences between those two groups (P> 0.05)
4.The Utilization of Health Service
(1)The situation of using health service
The two-week consultation rate of the elder left-behind was 14.90%, lower than these of elder not left-behind (15.80%).But there was no significant differences between the two groups (P> 0.05).②Among the patients who was sick in the past two weeks,73.79%the elder left-behind and 75.79%the elder not left-behind did not visit doctors. The the first three reasons for not visiting doctors were economic difficulty, thinking that disease is mild, having related drug.③The hospitalization rate of the elder left-behind was 16.86%, and these of elder not left-behind was 15.93%.④The non-hospitalization rate of the elder left-behind and the elder not left-behind were 48.19%and 53.93%respectively. The first three reasons for not accepting hospitalization were economic difficulty, unattended, thinking that disease is mild.
(2) Univariate analysis
①Gender, registered permanent residence, education level, occupation, source of income, economic status, suicide ideation, situation of chronic disease, stimulus quantity of negative life events and sleep quality were associated with the two-week prevalence.②Age, marital status, education level, economic status, suicide ideation, situation of chronic disease, self-rated health status, sick or not within the past two weeks, and hospitalization or not within the past one year were associated with the two-week consultation rate.③Gender, drinking, ADL, stimulus quantity of negative life events and sleep quality were associated with chronic disease prevalence.④Age, marital status, education level, economic status, medical insurance, situation of chronic disease, self-rated health status, ADL, and stimulus quantity of negative life events were associated with the hospitalization rate within the past one year.
(3)Multivariate Analysis of Health Service Utilization
The Logistic Stepwise Regression show:Occupation, self economic status arid the situation of chronic disease were the influencing factors of two-week prevalence; Age and the situation of chronic disease were related with the two-week consultation rate; Drinking, stimulus quantity of negative life events and sleep quality were the influencing factors of chronic disease prevalence. Marital status, medical insurance, self-rated health status, and ADL were associated with the hospitalization rate within the past one year.
Conclusions
1. The rate of the elder left-behind in Hengyang County is 24.83%.
2. Being left-behind could bring negative effects on physical and psychological health of the rural elder.
3.Being left-behind can not improve the economic status of rural elder popultaion, however it could change the structure of the family and created the new family structure which is dominated by inter-generational family members. This situation increased agricultural labor for the rural elder and resulted in the lack of child caring and other issues.
4.Gender, self-rating economic status, smoking, quantity of chronic disease, two-week prevalence, activity of daily living were associated with the physical function. Gender, self economic status, quantity of chronic disease, two-week prevalence, stimulus quantity of negative life events were associated with the psychological health.
5.Among the elder left-behind in Hengyang county, the prevalence of chronic diseases and the two-week prevalence rate was higher than the national average level in 2008. The two-week consultation rate was the same as the national average level.
6.Occupation, self-rated economic status and situation of chronic disease were associated with the two-week prevalence; Age and situation of chronic disease were associated with the two-week consultation rate. Drinking, stimulus quantity of negative life events and sleep quality were associated with chronic disease prevalence. marital status, medical insurance, self-rated health status, and ADL were associated with the hospitalization rate within the past one year.
The Value and Innovation
China's economic and social development is in the transition period and the health system is also facing reform, the research on general situation, life quality, health status, and health service of the elder left-behind could reveal the characteristics of this special population in rural areas and reflect the fundamental problems. We hope the whole society and government could pay more attention to the elder left-behind popultaion, and show concern about their living status and needs, which could make real achievement on social equity and harmony effectively when making the rural pension policy and rural health policy.
Through systematically analyzing the effects caused by being left-behind and the conception of the elder left-behind popultaion, our research made the conception to the elder left-behind population for reference of the other academic studies. The version SF-36 V2 Scale was firstly implicated to the rural elder, which provided the basis for the promotion.2Our research analyzed the associated facts for the life quality and health service utilization among the elder left-behind population.
随着我国工业化、城镇化进程的加快,人口流动特别是农村人口向城市以及经济发达地区流动已经成为不可逆转之势,也是我国经济发展和社会转型的必然,农村留守已经成为一个普遍的现象。农村留守老人虽然可能得到外出打工、经商等子女经济上的资助,但由于随着年龄的增长,老年人的健康状况和各项生理功能逐渐下降,加上子女不在身边,缺乏亲情的慰籍,生活上得不到关怀,体力上得不到的帮助,有些甚至还要承担抚养、照料、教育孙代的责任,耕种子女外出后留下的责任田,从而形成了一个具有特殊需要和问题的老年群体；长期留守,除了导致留守老年人身心健康的影响外,还可以引起一系列的社会问题,最基本的问题如老年人的生命安全、经济供养、生活照顾、医疗保障、精神慰籍等；较深层次的社会问题也逐渐凸显,如农村养老制度和机制的建立,国家对农村老年人问题的经济承受能力,社会的稳定、青年人对老龄化社会的责任感,和谐社会的构建等。农村留守老年人作为我国经济发展和社会变迁过程中产生的弱势群体,农村留守老人成为我国经济发展和人口老龄化进程中不可忽视的重要问题之一,改善他们的健康状况、提高他们的生活质量和卫生服务利用水平是社会医学和卫生事业管理研究领域的一项重要的课题,对于构建社会主义和谐社会、实现新农村建设的目标具有重要的现实意义。在我国研究探索新一轮医药卫生体制改革之时,为了进一步完善我国农村医疗卫生服务体系和医疗保障制度,研究农村留守老年人的医疗卫生服务利用具有一定的现实意义和价值。
农村留守老人日渐引起了学术界的关注。现有的研究表明：①对农村留守老人的研究,国内学者主要集中在对农村留守老人的成因、生活质量、生活满意度、生活照料、老年人的居住、社会互助机制、子女外出后对老人的供养、面临的困难和问题以及家庭关系等；②现有的研究主要是从人口学和社会学的角度进行,研究方法主要以定性研究为主。但是,对于农村留守老人的定义,目前学术界还没有给出一个规范的可操作性的定义；即使有个别学者对农村留守老人的生活质量进行了研究,但是并不系统、全面,研究结果主要也还停留于对其健康状况的描述,缺乏对影响农村留守老人健康因素的深入分析；③对农村留守老人卫生服务利用的研究还未见报道。
研究目的
本研究的目标是通过对农村留守老人的一般特征、健康状况、生活质量评价及影响因素、健康与卫生服务利用的评价及影响因素的研究,为提高农村留守老年人生活质量、建立农村留守老人养老机制、提高卫生服务利用率、讨论解决农村留守老人健康问题的提出措施和建议,并为政府和社会解决此类问题提供理论基础,为探索农村卫生体制改革提供科学依据。
研究目的：
1.描述农村留守老人的一般特征；
2.定量评价农村留守老人的生活质量,分析影响农村留守老人生活质量的主要因素；
3.定量评价农村留守老人的健康与卫生服务利用状况,分析影响农村留守老人健康与卫生服务利用的主要因素；
4.提出改善农村留守老人健康状况的政策建议。
研究方法
本研究将农村留守老人尝试定义为：年龄在60岁以上,有健存子(媳)女(婿),且所有子(媳)女(婿)外出至本乡镇外6个月以上,子(媳)女(婿)外出后不能履行正常的照料义务,因种种原因不能随子女一起居住而留守在原户籍地生活的农村老年人。
1.研究现场与样本
(1)研究现场
本研究的研究现场选在湖南省衡阳县。衡阳县是湖南省88各县(县级市)之一,隶属于湖南省第二大城市衡阳市。衡阳县现辖26个乡镇,893个村。2007年年末人口111.47万,是衡阳市第二个人口大县。该县现有农业人口80.38万,2007年外出务工农村劳动力16.37万,是典型的农业大县。衡阳县人口总数在湖南省88个县(县级市)中处于第七位左右,人均国民生产总值处于湖南省各县(县级市)的中位,农民人均纯收入处于中上水平。在对农村留守老人的研究中,选择衡阳县具有一定的代表性。
(2)研究样本
采用分层、整群、随机抽样方法,首先根据上一年度农民人年均纯收入将衡阳县的26个乡镇分为经济状况好、中、差三个层次,从每层中各选择1个乡镇为研究现场,再从每个乡镇的所有行政村中各随机抽取3个村,以9个行政村的所有符合条件的老年人作为研究样本。
2.研究的内容与研究工具：
(1)老年人的一般人口学资料：采用自制的基本情况调查表,内容包括性别、年龄、婚姻状况、受教育程度、经济状况、经济来源、生活习惯、居住状况、子女状况等；
(2)健康状况与医疗卫生服务情况：参考全国卫生服务调查的有关指标自制调查表,主要指标包括慢性病患病率、两周患病率、两周就诊率、两周患者未就诊率、住院率、未住院率；
(3)健康相关生命质量：采用中文版SF-36 v2量表(the version 2 of the SF-36 health survey);
(4)日常生活能力：采用日常生活能力量表(Activities of Daily Living Scale, ADL);
(5)负性生活事件：使用肖林等制订的老年人生活事件量表(Life Events Scale for the Elderly, LESE)；
(6)睡眠质量：采用匹兹堡睡眠质量指数量表(PSQI)。
3.资料收集方法
由于受农村老年人文化程度的影响,本研究采取面对面访谈法,由调查员根据调查表内容逐条询问,老年人根据自身实际情况作答,调查员进行记录。
4.质量控制
本研究通过预调查、对调查员的统一培训、选择可靠的向导、制定质量控制表、双人数据录入等措施对调查质量进行控制。通过对调查员的一致性、各量表的重测信度评价,考量问卷的信度。
5.资料分析方法
采用EpiData 3.0建立数据库,用SPSS 13.0建立数据库并进行统计学分析,取检验水准(α)为0.05。运用描述性分析法、比较分析法、Pearson相关分析、Ordinal回归分析法、logistic逐步回归分析法对调查资料进行分析。
结果
资料收集于2009年2月10日至5月28日完成。调查的9个村共有1198名60岁及以上老年人,符合条件的有1126人,实际访谈到的有1042人,应答率为92.54%,有效样本1040人,资料的有效率99.82%,因研究需要,剔除无健存子女研究对象13人,进入分析的老年人共有1027人。
1.农村留守老人的一般情况
(1)样本中24.83%的老年人符合本研究“留守老年人”的定义。
(2)农村老年人子女外出情况
根据研究的定义,在1027名研究对象中,有部分子女外出的老年人占58.23%,所有子女全部外出的老年人占24.83%,没有子女外出的老年人占16.94%。
样本人群子女外出至外省占大部分,为70.5%；外出从事打工者占84.5%；外出时间超过三年者占91.42%；外出子女0.5-1年回家探亲一次者占40.8%,1-2年回家探亲一次者占33.4%。
(3)农村留守老人一般特征
1027名老年人中留守老年人255名,非留守老人772名。留守老人中男性占64.70%,女性占35.30%。
留守老年人与非留守老年人一般情况比较：留守老人年龄小；男性比例高；控制年龄因素以后,60-69岁组和70-79岁组配偶健在的比例高、60-69岁组和70-79岁组受教育的程度高；控制性别、年龄因素以后,自杀意念发生率高(P<0.05)；与孙辈居住的比例高；留守老人经济来源主要是自己、医疗费主要由自己支付,非留守老人经济主要来源于子女、医疗费主要由子女支付；患病时,留守老人自己照顾自己的比例高于非留守老人,由配偶照顾的比例和子女照顾的比例都要低于非留守老人(P<0.05)。其他如户籍、民族、自评经济状况、喝酒情况、吸烟、睡眠情况等无差别(P>0.05)。
两组老年人躯体生活自理(PSMS)、工具性日常生活能力(IADL)、总量表(ADL)得分经比较有统计学意义(P<0.05),非留守老人得分高于留守老人。留守老年人发生率排在前五位的生活事件分别为“子女长期离家”(96.86%)、“患有慢性疾病”(78.43%)、“家庭经济困难”(33.73%)、“本人住院治疗”(27.45%)、“家庭成员住院治疗”(27.06%)；非留守老年人发生率排在前五位的生活事件分别为“患有慢性疾病”(82.90%)、“子女长期离家”(73.96%)、“家庭经济困难”(39.77%)、“配偶死亡”(33.68%)、“本人住院治疗”(29.66%)。两组老年人负性生活刺激量比较无差别(P>0.05)。
2.农村留守老人生活质量
(1)留守对农村老年人生活质量的影响
分别以农村老年人的生理健康和心理健康为应变量,以留守等因素作为自变量,进行单因素和多因素ordinal分析回归分析显示,留守降低了农村老年人心理健康水平(P<0.05)。
(2)农村留守老人生活质量影响因素的单因素分析
①一般情况：性别、年龄、户口、教育水平、职业、经济状况、医疗保险、喝酒、娱乐休闲、自杀等10个因素是生理健康的影响因素(P<0.05)；经济状况是心理健康的影响因素(P<0.05)。
②两周内是否患病：两周内没患病的留守老在生理功能(PF)、生理职能(RP)、躯体疼痛(BP)、社会功能(SF)、情感职能(RE)、精神健康(MH)、总体健康总体自评(GH)个7维度及生理健康得分高比两周内患病的留守老人(P<0.05)。
③ADL：日常生活功能正常的留守老人在生理功能(PF)、生理职能(RP)、躯体疼痛(BP)、社会功能(SF)、情感职能(RE)、精神健康(MH)、总体健康总体自评(GH)个7维度及生理健康得分高于日常生活功能障碍的留守老人(P<0.05)。
④负性生活事件：生活刺激量小组的留守老人在生理功能(PF)、生理职能(RP)、躯体疼痛(BP)、社会功能(SF)、情感职能(RE)、精神健康(MH)、总体健康总体自评(GH)个7维度及生理健康和心理健康得分高于生活刺激量大组(P<0.05)。
⑤睡眠质量：睡眠质量好的留守老人在生理功能(PF)、生理职能(RP)、躯体疼痛(BP)、社会功能(SF)、情感职能(RE)、总体健康总体自评(GH)6个维度及生理健康、心理健康得分高于睡眠质量差的留守老人(P<0.05)
(3)多因素分析
采用Ordinal逐步回归分析显示：①性别、自评经济状况、吸烟、慢性病种数、两周患病情况、日常生活能力是留守老人生理健康的影响因素；②性别、自评经济状况、慢性病种数、两周患病情况、负性生活事件刺激量是留守老人心理健康的影响因素。生理健康和心理健康Ordinal逐步回归方程分别为(性别X1,自评经济状况X7、吸烟X10、慢性病种数X15、两周内是否患病X16、日常生活能力X17、负性生活事件刺激量X18)：Logt1=-10.535+1.688X1+1.221X7+0.985X7+0.887X10+1.850X15+1.271X 16+2.923X17 Logit2=-7.425+1.688X1+1.221X7+0.985X7+0.887X10+1.850X15+1.271X1 6+2.923X17; Logit1=21.300+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18 Zogit2=24.306+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18
3.农村留守老人就医行为及健康状况
(1)农村老年人就医医疗机构的选择
①门诊在村卫生室或个体诊所、卫生院的占70%以上。②留守老人35.4%在卫生院住院,40.0%在县级医院住院,24.6%在市级以上医院住院；非留守老人43.7%在卫生院住院,26.5%在县级医院住院,29.8%在市级以上医院住院。
(2)两周患病率与慢性病患病率
留守老人与非留守老人两周患病率分别为56.86%和65.28%,控制性别和年龄因素以后,两组老年人两周内患病率差异无统计学意义(P>0.05)。
留守老人与非留守老人的慢性病患病率分别为63.92%和65.67%,两组老年人慢性病患病率差异无统计学意义(P>0.05)。
4.留守老人健康卫生服务利用
(1)卫生服务利用的状况
①留守老人和非留守老人两周就诊率分别为14.90%和15.80%,两组老年人两周就诊率差异无统计学意义(P>0.05)。②留守老人、非留守老人两周患者未就诊率分别为73.79%和75.79%。留守老人与非留守老人排前三位未就诊原因依次是经济困难、自认为病情轻、自己有药品。③住院率：留守老人、非留守老人一年内住院率分别为16.86%和15.93%。④未住院率及原因：留守老人、非留守老人未住院率分别为48.19%和53.93%。留守老人与非留守老人排前三位未住院原因依次是经济困难、没人陪、自认为病情轻。
(2)健康及卫生服务利用影响因素的单因素分析
①性别、户籍、受教育程度、职业、经济来源、经济状况、自杀意念、有无患慢性病、负性生活刺激量、睡眠质量10个因素对留守老人两周患病率有影响；②年龄、婚姻状况、受教育程度、经济状况、自杀意念、有无患慢性病、自评健康状况、两周内有无患病、一年内有无住院9个因素对留守老人两周就诊率有影响；③慢性病患病率：性别、喝酒、ADL、负性生活事件刺激量、睡眠质量5个因素对留守老人慢性病患病率有影响；④年龄、婚姻状况、受教育程度、经济状况、医疗保险、有无患慢性病、自评健康状况、ADL、负性生活刺激量5个因素对一年内住院率有影响。
(3)健康及卫生服务利用的多因素分析
logistic逐步回归分析显示,职业、自评经济状况、有无慢性病为两周患病率的影响因素；年龄、有无慢性病为两周就诊率的影响因素；喝酒、负性生活事件刺激量、睡眠质量为慢性病患病率影响因素；婚姻状况、医疗保险、自评健康状况、ADL为一年住院率的影响因素。
结论
1.衡阳县农村老年人的留守率为24.83%。
2.留守降低了农村老年人的心理健康和生理健康水平。
3.留守并没有改善农村老年人的经济供养状况,而是导致农村家庭结构发生了改变,出现了以隔代家庭为主的家庭结构模式,加重了农村老年人的农业劳动,造成了子女照料的缺失等问题。
4.影响农村留守老人生理健康的因素有：性别、自评经济状况、吸烟、慢性病种数、两周患病情况、日常生活能力；影响心理健康的因素有：性别、自评经济状况、慢性病种数、两周患病情况、负性生活事件刺激量。
5.衡阳县农村留守老人慢性病患病率和两周患病率高于2008年全国农村老年人平均水平,两周就诊率与全国农村老年人基本持平。
6.职业、自评经济状况、有无慢性病是农村留守老人两周患病率的影响因素；年龄、有无慢性病为两周就诊率的影响因素；喝酒、负性生活事件刺激量、睡眠质量为慢性病患病率影响因素；婚姻状况、医疗保险、自评健康状况、ADL为一年住院率影响因素。
本研究的价值与创新
在我国经济与社会发展处于转型时期,在医药卫生体制改革之时,对农村留守老人的一般情况、·生活质量、健康状况、和卫生服务利用加以研究,揭示这个农村特殊人群的特点,反映其存在的问题,希望引起社会和政府对他们的关注和关心,在农村养老政策、农村卫生政策制定之时要充分考虑社会弱势群体的现状和需求,切实做到社会的公平与和谐。
本研究通过对衡阳县农村老年人子女状况的调查,以及留守给农村老年人带来的影响,并对农村留守老人的概念加以梳理和辨析,给出农村留守老人的概念,以便于学术界在对农村留守老人的研究提供参考。首次应用中文版SF-36 V2量表对农村老年人的生活质量进行评价,为该量表的推广应用提供依据,并对农村留守老人质量的影响因素进行分析。对农村留守老人的医疗服务利用及影响因素进行全面的分析。
Background
With the accelerated industrialization and urbanization of our country, the population movement, especially that rural population who migrates to the urban areas or economically developed areas has become irreversible. And it is also an inevitable phenomenon for our country's economic development and social transformation. Therefore, the left-behind population has become a common phenomenon. Although the elder left-behind can get some financial support from their children who has gone out for work, their health condition and physiological function are decreasing when the time past, and can not get a concern in nearby, lacking the comfort of kinship and the physical help. Some even still need to undertake the responsibility to take after and educate the offspring, or cultivate responsible farmlands which were left behind by their going out families. Therefore they become a population with special needs and problems. Long-term being left behind could bring psychological or physical health affects on the elder, as well as series of social problems. For example, the most essential problems are safety, economic support, daily care, medical care, spiritual comfort and so on. Deeper levels of social problems showed gradually as well, such as the establishment for rural pension system, financial capacity for the rural elder of our country, social stability, sense of responsibility of the young for the aging society, the establishment of harmonious society and so on. During the process of economic development and social changes, the elder left-behind becomes one of the important problems that can't be ignored in the process of our country's economic development and population aging. To improve the quality of their life, to better use of health service are the impressing problems in the field of social medicine and health service management, which would bring important practical significance for building a socialist harmonious society and realizes the aim of building new countryside. Hence, to study on the medical and health services utilization of the elder left-behind could bring practical significance and value for the improvement of the rural health service system and medical security system. The elder left-behind becomes the focus of the academia. The previous. studies had showed that①Most of the previous national scholars have been focused on causes of left behind problems, life quality, life satisfaction, life care, living condition, Social Solidarity mechanism, support, difficulties, problems,family relationships of the elder when their children going out, and so on;②The previous researches were mainly discussed the problem from the demographic and sociological aspects and most were the qualitative researches. However, no operational definition has been given by the current academia to the elder left behind. Though several researches have studied the life quality of the elder left behind, they were not systematical and comprehensively. The findings also mainly remained at the description of their health condition, lacking of in-depth analysis of health factors affecting the elderly staying in rural areas.③Studies on the use of health services for the elder left-behind population has not been reported.
Objectives
Via studying the general characteristics, health status, life quality and putative influencing factors, health and health care utilization and putative influencing factors among the elder left-behind population, we aims at giving advise and suggestion on improving the life quality of the elder left-behind population, establishing their pension system, increasing utilization of health services, discussing and solving their health problem. We also could give the theoretical basis for solving such problems to the government and the communities, and scientific basis for exploring health system reform in the rural areas as well.
1. Describe the general characteristics of the elder left-behind popultaion.
2. Quantitatively evaluate the life quality among the elder left-behind population and analyze the main influence factors.
3. Quantitatively evaluate health and health service utilization among the elder left-behind population and analyze the main influence factors.
4. Give suggestions on the health policy for the improvement of health conditions of the elder left-behind population.
Methods
The study attempted to define " Elder left-behind " as the rural elderly who cannot live with their family members for a variety of reasons, over 60 years of age, having surviving children (including daughter-in-law and son-in-law)who went out to the outside of the town for more than 6 months and cannot carry out the duty of maintenance.
1.Study area and Study population
(1)Study area
The study area is in Hengyang County of Hunan province. Hengyang is one of the 88 counties (county-level cities), belonging to the second largest city-Hengyang City which has 26 towns and 893 villages. At the end of 2007, it is the second most populous city of Hengyang City with a population of 1,114,700. It is a typical agricultural county with 803 800 agricultural population and163 700 migrant workers. In the study of the elder left behind, with the population ranking at the seventh and the per-capita GDP being in the middle level among 88 counties of Hunan Province, the per-capita net income of farmers being in the upper level, Hengyang County could be a representative sample,.
(2) Study population
Using multi-stage stratified cluster sampling, Firstly we divided the 26 townships into three layers according to the economic level (good、Medium and poor).Then one township was selected from each level and three villages were randomly selected from every township. Finally, all qualified old people of nine villages were selected as study population.
2.Research Content and Instrument
(1) General demographic data:Demographic variables were collected using self-made basic situation questionnaire. The contents involves gender, age, marital status, educational level, economic status, source of income, living habits, living conditions and child status etc al.
(2)Health Status and Medical Service:We made the situation questionnaire with indices including prevalence of chronic diseases, two-week prevalence, two-week consultation rate, two-week non-consultation rate, hospitalization rate,non-hospitalization rate.
(3) QOL:The quality of Life was collected using the version 2 of the SF-36 health survey.
(4) Activity of Daily Living:Activities of Daily Living Scale was used.
(5)Negative Life Events:Life Events Scale for the Elderly which was made by XiaoLin etc.
(6)Sleep Quality:PSQI was used to measure sleep quality.
3.Data Collection
Owing to the education level of the old, the face to face interview was adopted. The investigator asked the contents of the questionnaire one by one and recorded the results according to the answer of interviewees.
4.Quality Control
The quality of research was controlled by adopting piolt investigation, trained investigators,selecting credible guider,using quality control table,double data entry etc al. The reliability was measured by using the Consistency of investigator,test-retest reliability.
5.Data Analysis
EpiData 3.0 was adopted to establish data-base. SPSS 13.0 was used in all analyses. The data was analyzed by using descriptive analysis, comparative analysis, Pearson correlation analysis, Ordinal regression, Logistic progressive regression analyses. And the level of significance is 0.05.
Results
Data has been collected during February 10,2009 and May 28,2009. In the nine villages, there were 1198 elderly people aged 60 years and older, of which 1126 were qualified as our target population. Finally 1042 were investigated, the response rate was 92.54%. Except two persons, all the 1040 had completed information. For research,13 were eliminated because of having no surviving child.
1.The general Characteristics of Rural Remained Elderly
(1)24.83%of the total sample accorded with the definition of "Elder left behind".
(2)Imgration Situation of the children
Based on the definition, in the 1027 objects, there is 58.23% population having some of children going out and 24.83%having all of the children going out, left only 16.94%having no children going out for work.
The five most prevalent situations were "Going out to other provinces" (70.5%), "going out for work" (84.5%), "going out for more than three years (91.42%), "Back home once every 0.5-1 years" (40.8%)and "back home once every 1-2years"(33.4%).
(3) The general Characteristics of Rural Remained Elderly
In the 1027 objects,255 were the elder left-behind, in which male accounted for 64.70%.
The general comparison between the elder left-behind and the elder not left-behind:the elder left-behind population were younger, more likely to be male; After controlling the age factors,60-69 age group and the 70-79 age group had higher proportion of surviving spouses, and 60-69 age group and the 70-79 age group had higher level of education; Controlling for both gender and age, remained elderly had higher incidence of suicidal ideation and higher proportion of living with grandchildren (P<0.05); Among the elder left-behind group, the daily expenses and medical fees are more likely to be paid by their own,while among the elder not left-behind group, the daily expenses and medical fees are more likely to be paid by their children; When being sick, the elder left-behind population had higher proportion of taking care of themselves than the elder not left-behind population and had lower proportion of nursing by their children (P<0.05).The situations did not differ significantly in terms of household registration, nation, self-rating economic status, drinking, smoking, sleeping.
The elder left-behind group had significantly higher scores in PSMS, IADL, ADL (P< 0.05). The five most prevalent life events for the elder left-behind population were " children for long-term immigration' (96.86%), "suffering chronic disease" (78.43%), "family financial difficulties" (33.73%), "self-hospitalization" (27.45%), "family member hospitalization" (27.06%). The five most prevalent life events for the elder not left-behind were " suffering chronic disease " (82.90%), "children for long-term immigration" (73.96%), "family financial difficulties"(39.77%)," loss of spouse"(33.68%), " self-hospitalization" (29.66%). The stimulus quantity of negative life events did not differ significantly between the two groups (P> 0.05)
2.The life quality of rural remained elderly
(1)The effects of "left-behind" on rural elder
Regarding Rural physical and psychological health as dependent variables, "left-behind" as independent variables, univariate and multivariate analysis of ordinal regression analysis showed that "left-behind" decreased psychological health condition (P<0.05).
(2)Univariate analysis
①General condition:Gender, age, registered permanent residence, education level, occupation, economic status, medical insurance, drinking, amusement and suicide were associated with physical health; Economic status were associated with psychological health.
②two-week prevalence:The elder left-behind who were not sick in past two weeks had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, psychological health, general health (P< 0.05)
③ADL:The elder left-behind who had normal activity of daily living had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, mental health, general health (P< 0.05).
④negative life events:The elder left-behind who had low stimulus quantity of negative life events had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, mental health, general health (P< 0.05)
⑤leep quality:The elder left-behind who had good sleep quality had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, general health (P< 0.05)
(3)Multivariate Analysis
The Ordinal Stepwise Regression show:①Gender, self-rating economic status, smoking, quantity of chronic disease, two-week prevalence, activity of daily living were the influencing factors of physical function. Gender self-rating economic status, quantity of chronic disease,two-week prevalence, stimulus quantity of negative life events were the influencing factors for psychological health. The Ordinal Stepwise Regression equation were (GenderX1, self-rating economic status X7、smoking X10、quantity of chronic disease X15 two-week prevalenceX16、activity of daily livingX17、stimulus quantity of negative life events X18): Logitl=-10.535+1.688Xl+1.221X7+0.985X7+0.887X10+1.850X15+1.2 71X16+2.923X17 Logit2=-7.425+1.688X1+1.221X7+0.985X7+0.887X10+1.850X15+1.27 1X16+2.923X17; Logitl=21.300+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18 Logit2=24.306+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18
In the village health clinics or private clinics, hospitals accounted for more than 70%.②35.4%of elderly people staying in hospitals hospital, 40.0%in the county hospital,24.6%more than in the municipal hospital; 43.7%of non-Aging hospitalized in hospitals,26.5%in the county hospital,29.8%in municipal above hospital.
3.Health seeking behavior and health status
(l)Health seeking behavior of rural elderly
①70%of population chose village health clinics, private clinics or rural public health centre.②35.4%of the elder left-behind hospitalized in rural public health centre,40.0%in county hospital, and 24.6%in Municipal level and above hospital; 43.7%of elder not left-behind hospitalized in rural public health centre,26.5%in county hospital and 29.8%in Municipal level and above hospital.
(2)Two-week prevalence and chronic disease prevalence
The two-week prevalence of the elder left-behind was 56.86%, lower than these of elder not left-behind (65.28%). But after controlling for gender and age, there was no significant differences between those two groups (P>0.05)
The chronic disease prevalence of the elder left-behind was 63.92%,lower than these of elder not left-behind (65.28%). But there was no significant differences between those two groups (P> 0.05)
4.The Utilization of Health Service
(1)The situation of using health service
The two-week consultation rate of the elder left-behind was 14.90%, lower than these of elder not left-behind (15.80%).But there was no significant differences between the two groups (P> 0.05).②Among the patients who was sick in the past two weeks,73.79%the elder left-behind and 75.79%the elder not left-behind did not visit doctors. The the first three reasons for not visiting doctors were economic difficulty, thinking that disease is mild, having related drug.③The hospitalization rate of the elder left-behind was 16.86%, and these of elder not left-behind was 15.93%.④The non-hospitalization rate of the elder left-behind and the elder not left-behind were 48.19%and 53.93%respectively. The first three reasons for not accepting hospitalization were economic difficulty, unattended, thinking that disease is mild.
(2) Univariate analysis
①Gender, registered permanent residence, education level, occupation, source of income, economic status, suicide ideation, situation of chronic disease, stimulus quantity of negative life events and sleep quality were associated with the two-week prevalence.②Age, marital status, education level, economic status, suicide ideation, situation of chronic disease, self-rated health status, sick or not within the past two weeks, and hospitalization or not within the past one year were associated with the two-week consultation rate.③Gender, drinking, ADL, stimulus quantity of negative life events and sleep quality were associated with chronic disease prevalence.④Age, marital status, education level, economic status, medical insurance, situation of chronic disease, self-rated health status, ADL, and stimulus quantity of negative life events were associated with the hospitalization rate within the past one year.
(3)Multivariate Analysis of Health Service Utilization
The Logistic Stepwise Regression show:Occupation, self economic status arid the situation of chronic disease were the influencing factors of two-week prevalence; Age and the situation of chronic disease were related with the two-week consultation rate; Drinking, stimulus quantity of negative life events and sleep quality were the influencing factors of chronic disease prevalence. Marital status, medical insurance, self-rated health status, and ADL were associated with the hospitalization rate within the past one year.
Conclusions
1. The rate of the elder left-behind in Hengyang County is 24.83%.
2. Being left-behind could bring negative effects on physical and psychological health of the rural elder.
3.Being left-behind can not improve the economic status of rural elder popultaion, however it could change the structure of the family and created the new family structure which is dominated by inter-generational family members. This situation increased agricultural labor for the rural elder and resulted in the lack of child caring and other issues.
4.Gender, self-rating economic status, smoking, quantity of chronic disease, two-week prevalence, activity of daily living were associated with the physical function. Gender, self economic status, quantity of chronic disease, two-week prevalence, stimulus quantity of negative life events were associated with the psychological health.
5.Among the elder left-behind in Hengyang county, the prevalence of chronic diseases and the two-week prevalence rate was higher than the national average level in 2008. The two-week consultation rate was the same as the national average level.
6.Occupation, self-rated economic status and situation of chronic disease were associated with the two-week prevalence; Age and situation of chronic disease were associated with the two-week consultation rate. Drinking, stimulus quantity of negative life events and sleep quality were associated with chronic disease prevalence. marital status, medical insurance, self-rated health status, and ADL were associated with the hospitalization rate within the past one year.
The Value and Innovation
China's economic and social development is in the transition period and the health system is also facing reform, the research on general situation, life quality, health status, and health service of the elder left-behind could reveal the characteristics of this special population in rural areas and reflect the fundamental problems. We hope the whole society and government could pay more attention to the elder left-behind popultaion, and show concern about their living status and needs, which could make real achievement on social equity and harmony effectively when making the rural pension policy and rural health policy.
Through systematically analyzing the effects caused by being left-behind and the conception of the elder left-behind popultaion, our research made the conception to the elder left-behind population for reference of the other academic studies. The version SF-36 V2 Scale was firstly implicated to the rural elder, which provided the basis for the promotion.2Our research analyzed the associated facts for the life quality and health service utilization among the elder left-behind population.
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