基于倡导促动理论的老年人多重慢病健康管理策略研究：理论模型、行为模式与管理路径

At present, China has entered a rapid aging period, which features high group incidence and large aging population base. Chronic disease has become the number one threat to the elderly. Due to the coexistence of multiple diseases and the intertwinement of various factors, the situation of multimorbidity is more severe. As a result, the rapid growth of medical expenses and the increasing burden on families are more and more obvious. The elderly with multimorbidity has become a major social issue related to thousands of households, the construction of a harmonious society as well as the realization of "Healthy China 2030". From such perspectives, this project chose the geratic patients with multimorbidity as the research object, and proposed a health management strategy which is suitable for the elderly with multimorbidity in China based on the advocacy theory framework. In this project, a theoretical model was based upon the systematic review and other methods: the influencing factors and related mechanism of the elderly with multimorbidity were analyzed through Path Analysis with Latent Variables (PA-LV) model; K-Means clustering method was used to classify multimorbidity behavior patterns of the elderly; and the Difference in Difference (DID) model was used to evaluate the effect of health management strategy. Meanwhile, to verify the applicability of advocacy theory, multimorbidity risk assessment system and health behavior comprehensive assessment system were designed during the research process. Furthermore, with the combination of theory and empirical research, this project aims to provide a new idea and a feasible path for the "aging" and "disease chronicity" problems in China.

当前我国已进入快速老龄化时期，群体发病率高、老龄人口基数大等特征显著。慢性病现已成为老年人最主要的健康威胁，由于多重疾病并存、多种影响因素交织，导致多重慢病形势更为严峻，也因此造成医疗费用快速增长、家庭经济和照护负担不断加重。老年人多重慢病问题已成为关系千家万户、影响和谐社会构建及“健康中国2030”实现的重大社会问题。本项目以此为视角，选择老年多重慢病患者为研究对象，利用倡导促动理论框架，提出适宜我国国情的老年人多重慢病健康管理策略。项目采用系统性评价等方法构建理论模型，利用PA-LV模型分析老年人多重慢病影响因素及相关机制，利用K-Means聚类法归纳老年多重慢病患者行为模式，采用双重差分模型对健康管理策略进行效果评价，验证倡导促动理论的适用性，同步研发多重慢病风险评估系统与健康行为综合评价系统。本项目将理论与实证研究相结合，旨在为应对我国“老龄化”“慢病化”问题提供新思路及有效途径。

当前我国已进入快速老龄化时期，老年群体慢性病发病率高、人口基数大等特征显著。此外，因多种慢病并存、各类影响因素交织，导致老年群体医疗费用增长、家庭经济和照护负担加重。老年人多重慢病问题已成为关系千家万户、影响和谐社会构建及“健康中国2030”实现的重大社会问题。本项目以此为切入点，选择老年多重慢病患者为研究对象，基于倡导促动理论框架，提出适宜我国国情的老年人多重慢病健康管理策略，主要研究内容包括：倡导促动框架下老年人多重慢病健康管理理论研究；老年人多重慢病健康管理实证研究；健康管理相关技术创新与工具研发共三部分。主要研究结果包括：通过理论与文献计量学分析，辨析多重慢病概念，挖掘多重慢病健康管理的重点与难点，构建倡导促动与健康管理相融合的理论框架和以行为改变技术为核心的社区老年人多重慢病健康管理服务路径。在山西省、广东省等地开展老年人群横断面调查与队列研究，对多重慢病影响因素、相关机制及患者行为模式展开分析，发现老年人群多重慢病发病率高，其模式主要由二元和三元疾病组合为主且城乡差异大，多数疾病与高血压、糖尿病密切相关。高龄、常住地为农村、低体力活动者、超重及肥胖等均是影响多重慢病发生与发展的重要因素。此外，老年多重慢病患者身心健康风险高，更容易出现抑郁、焦虑和压力等心理困扰，主观幸福感较低，生活自理能力（ADL）较差，且ADL的下降会造成更严重的心理问题，童年负性事件也会对其产生显著影响。多重慢病对老年人质量调整生命年有较大影响，健康促进生活方式对于多重慢病的健康管理至关重要。在技术创新与研发方面，自主研发了健康行为综合评价系统、多重慢病分类组合风险评估系统，实现了多重慢病健康管理的信息化与智能化。基于倡导促动理论的老年人多重慢病健康管理策略实现了宏观政策与微观大众双倡导，促使老年人群态度及行为发生改变，激发了该群体的社会参与度及幸福感，为应对我国“老龄化”“慢病化”问题提供新思路及有效途径。