Tài liệu Research on the needs, to meet of the health care service for the elderly and piloting a community-based intervention model in dong anh district, hanoi

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1 INTRODUCTION With the development of science and technology as well as the improvement of socio-economy, the average life expectancy is increasing. It is, therefore, the population of Vietnam is rapidly aging in both proportion, and absolute number. According to the Census of Population Fluctuations and Family Planning (01/4/2012), the proportion of the elderly (60 years or more) accounted for 7.2% of the population in 1989, 8.2% in 1999, 9.9% in 2011, and 10.2% in 2012. It is expected that the proportion could be dramatically reached 16.8% in 2029 and 22.0% in 2050. Thus, the statistics show that the number of elderly people in Vietnam is quickly increasing with the aging process during the last ten decades. How to reduce the progress of and the diseases for the older adults to prolong healthy life is an eternal desire of human. So, preventive medicine sector plays a crucial role in this task. Dong Anh district, a suburban district of Hanoi, has an area of 18.230 hectares, and a population of 276,750 people. Quick urbanization has been conducing in the district recent years. The number of elderly people in Dong Anh district is also increasing. The following question should be answered: (1) what are the health situation, and the demands for health care services of the elderly in Dong Anh? (2) How the responses of family and social to the elderly’s health care are? (3) What are the solutions from the local authorities, unions and commune health to meet the basic needs for health care of the elderly in the commune level? From the above reasons the research was conducted with the following objectives: 1. To describe the demands for health care services of the elderly people and the current response of commune health centers in Dong Anh district, Hanoi, 2012. 2. To assess the effectiveness of the community-based model to manage, consult, and care for the health of the elderly in two communes in Dong Anh district, Hanoi. 2 The novel contributions of the thesis: - Assessed the situation of demands, and the use of health care services for elderly people as well as the response of the commune health centers in Dong Anh district, Hanoi. - Developed and piloted the community-based model to manage, consult, and care for the health of the elderly successfully. The elderly was received health care activities, health counseling, and involve in health promotion activities of the research. Outdoor health clubs with exercises and physical activities, yoga, sport activities helped the elderly have healthy playground to encourage them participating in physical activities and health remaining. - Scientific information obtained from the elderly, commune health workers, local authorities etc. in this study will be the evidence for health policy makers, local authorities in terms of developing suitable models to manage and take care the elderly. Based on the results of this research, Hanoi People’ Committee will issue directions to enhance the quality of life for the older adults living in Hanoi, fulfilling the desire of older people to live happy, healthy, useful. Thesis structure: The thesis consists of 137 pages with 40 tables, 9 charts, 5 figures, including Introduction: 2 pages, Chapter 1: Background: 36 pages, Chapter 2: Method: 24 pages, Chapter 3: Results: 36 pages, Chapter 4: Discussion: 32 pages, Chapter 5: Conclusions: 2 pages, and Recommendations: 1 page. There are 101 references, of which 73 Vietnamese references, and 28 English references. Chapter 1 BACKGROUND 1.1. DEMANDS AND ABILITY TO MEET HEALTH CARE SERVICES FOR ELDERLY 1.1.1. Concept of the elderly The section The elderly and the interest of society in the book of International Encyclopedia of Sociology divides the elderly by age groups as follows: 3 + 65 -74: young elderly; 75-84: middle-aged elderly; >84: older elderly group. The World Health Organization (WHO) divides the ages of elderly people as below: + 60 - 74: Older adults; 75-90: elderly people; > 90: long life expectancy of elderly people. In terms of the Vietnamese Law, the article 2 of the Elderly Law (11/2009) defines that the elderly is "the Vietnamese people aged 60 years old or over". 1.1.2. The elderly worldwide and in Vietnam According to the rules of the United Nations, a country with a proportion of elderly from 10% or more is considered as aging population country. France had aging population in 1935 while Sweden in 1950. The speed of aging population in the 1990s of the 20th century and the first decade of 21th century in Vietnam was much faster than in 1980s, from 25% to 33% and 35%, higher than the rate of population growth (population increased 20% and aging population increased 25% between 1979-1989, the period from1989-1999 the population growth, and aging population are 18%, and 33%, respectively). From 1979 to 2007, the Vietnam’s population increased 1.61 times, while the elderly population increased 2.17 times. Speed of aging population our country is about 35 years with a proportion of elderly doubled from 5.8% in 1989) to an estimation of 14% in 2025. 1.1.3. Health care needs of the elderly The needs for health care is the urgent requirement of the elderly. This does not only depend on the subjective desire but also depends heavily on the quality, cost, level of illness, distance and the accessibility to the health care facilities of each person. In Vietnam, the health care needs of the elderly is very high (accounting for 84.4%) while the condition of the elderly themselves are very limited. Health care needs of the elderly is not just simply the daily care such as eating, and taking care when get illness, the elderly also has high demands for spirit care. 1.1.4. Access to health care services of the elderly In health care, the concept of accessibility can be considered the ability to contact and communicate to the health care services, where meet 4 the health care needs of the elderly. Access to the health services is completely different with the use of health care services. The use of health care services depends on the extent of the diseases, the availability of health services and many other factors. Accessability includes both sides, the elderly site and health care services site. It depends on many factors, including space, time, cost, availability, quality of service, social and cultural, and human. 1.1.5. The use of health care services of the elderly The use of health care services is the ability and the level of health facilities providing care, detection and treatment of different diseases according to the needs of each patient, and the diseases. This does not only depend on the subjective desire but also depends heavily on the quality, cost, level of illness, distance and the accessibility to the health facilities of the community. The main factors affecting the use of health care services are economic, consumers and service providers. 1.1.6. The ability to meet the elderly’s health care needs of health station The ability to meet the health care services is synthesis of different conditions and available resources of the health facilities that makes the health services meet the health care needs of the people. The ability to meet the health care needs of the health facilities including the following factors: health staff (health workers) in both quantity and quality, conditions to ensure the services (facilities, infrastructure ...); medical equipment (drugs, chemicals, tools ...); health budget (including state budget, local budget, and socialization ...); mechanisms and policies. 1.2. HEALTH CARE MODELS FOR ELDERLY 1.2.1. Health policy to care the elderly Recognizing the significance and importance of the health care for the elderly, the Vietnam Communist Party, and Vietnam Government have considered the care for physical life, spiritual of the elderly, in which health care is the moral of the nation, is the responsibility of the whole Party, the entire population and authorities. This has been reflected by the number of documents issued by the State policy in the care of elderly. 1.2.2. Health care models for the elderly Some currently health care models for elderly people in Vietnam: - Elderly health care model in the family. - Telecommunications medical model for elderly. 5 - Elderly health care model in the community. - Elderly health care model in the hospital. - Model of health club. In general, the deployment of model not synchronized, and not comprehensive. There are many factors barring the resources, facilities in order to maintain the models sustainable development in the community. Chapter 2 METHOD 2.1. Study subjects, location, and time 2.1.1. Subjects, research material * Subjects of research: - The elderly in the study areas. - The main caregivers for elderly in the family. - Health workers from the commune health center (CHCs), private clinics, village health workers. - Health facility leaders, managers, supervisors, and caregivers the elderly in the commune. - Infrastructure, medical equipment and drugs ... * Research material: - The legal documents of elderly health care. - Notebooks, reports of health care for the elderly in CHCs. 2.1.2. Study location: Research was conducted in the four communes in Dong Anh district, Hanoi, including Lien Ha, Co Loa, Uy No and Thuy Lam. 2.1.3. Research time The study was implemented from 01/2012 - 06/2013, dividing into 2 phases: - Phase 1: To describe of demand for health care services and the ability to meet the demand of the CHCs; building theoretical models from 01/2012 – 06/2012. - Phase 2: To implement interventional models and to evaluate the effectiveness of the model from 07/2012 - 6/2013. 2.2. Research methods 2.2.1. Study design 6 - Cross-sectional descriptive study: describes the demand for health care services elderly and ability to meet the demand of the commune health in Dong Anh district, Hanoi. - Intervention (cluster community-based randomized control trial): to build and test the community-based model to manage, consult, and care for the health of the elderly in two communes in Dong Anh district, Hanoi. 2.2.2. Sample size and sampling 2.2.2.1. The sample size for the cross-sectional descriptive study - The elderly: 1.025 people - Health workers in 4 study communes: 27 commune health workers; 29 village health workers. - The local leaders, managers in the communes: 4 communes x 9 = 36 people. - The main caregivers of the elderly: 971 people. - Research tools: questionnaires for each group. 2.2.2.2. Health examination All of the 1.025 elderly people in the four study communes was health checked. 2.2.2.3. The sample size of interventional study - The elderly: 512 people in two interventional communes; 506 people in the two control communes. - Health workers in 4 study communes: 56 commune health workers. - The local leaders, managers in the communes: 36 people. - The main caregivers of the elderly: 971 people. The model namely "The community-based model to manage, consult, and care for the health of the elderly" to be deployed which includes three key contents: - Content 1: Manage, health examination for the elderly in CHC. - Content 2: Communicate, guide, and consult about health for the elderly. - Content 3: Establish outdoor health clubs (OHC). 2.3. The variables, and indicators of the study 2.3.1. The variables of the study 2.3.1.1. The descriptive variables - Demographic characteristic variables of the elderly, including: age, gender, educational level, occupation, personal activities, health 7 status, health symptoms/illness, habits to use medical services, health care wishes, yoga and physical activity... - CHC, including: human resources, infrastructure, medical equipment, professional qualifications, medical activities about the elderly, the ability to meet the health services for the elderly (the availability, coverage). - Characteristics of the family, including: the family's concern to the health and illness, spiritual care for the elderly, the roles and responsibilities of the local authorities, agencies and organizations for elderly. 2.3.1.2. The analyzed variables - The health care needs of the elderly, including needs to manage health, health care in the community; health care at home, and in the CHCs; needs to be provided health information, and health education; needs of yoga practice, and physical activity clubs. - Ability of the CHCs to meet the demands: the ability to provide health management services , health care and health examination for the elderly; ability to provide information, health communication and guide the elderly to practice yoga. - Ability to mobilize community: the ability to mobilize the support, and participation of the local authorities, local offices, and families to manage, consult, and care the elderly’s health. 2.3.1.3. The interventional variables of the community-based model to manage, consult, and care for the health of the elderly Intervention model on the elderly health includes the following three components: Input Operating process Output - Inputs are indicators of resources, including human resources, infrastructure, medical equipment, medicine, finance, CHWs, VHWs, the commune leaders, the elderly, and other members of the families. - Outputs are the indicators of using health care services of the elderly; ability of the CHCs to meet the elderly’s health needs; the interest and the responsibilities of the closed relatives (members in the family) involve in taking care the elderly in the community; the interest of the local Party cadres, the local authorities, and local unions. 8 The operating process is the activities of the intervention included following indicators: + The indicator of the health examination situation of the (availability rate, accessibility rates, utilization rates, sufficient coverage rates, effective coverage rates). + The effectiveness assessment index of the intervention model: • Evaluate the change in health management, HE for the elderly: based on the health community-based monitoring indicators. • Assess the results of health communication and education (HCE). • Evaluate the effectiveness of the intervention model based on the effective indicator. 2.3.2. The study indicators 2.3.2.1. The use of health care services for elderly people * The use of healthcare services for the elderly: - Percentage of the EL took/did not take health examination routinely. - Percentage of the EL chose how to manage to illness. - Percentage the elderly went to health facilities when getting sick. * The level of access to medical services and health workers when getting sick: - Percentage of the EL asked physicians to their home. - Percentage of the EL went to the hospital immediately when getting sick. - Percentage of the EL was instructed how to care, follow-up, and treatment. * The level of access to information related to health, disease in the EL: - Percentage of the EL heard about diet and physical activity. - Percentage of the EL heard about heart disease - arteries, high blood pressure (HBP). - Percentage of the EL people heard of musculoskeletal, cancers ... * Aspirations of older people in health care: - Percentage of the seniors who wish to be provided services HC at home. - Percentage the EL to be health checked routinely. - Percentage the EL was provided disease prevention information by health workers. - Percentage of the EL involved in physical activity, yoga... 2.3.2.2. The ability of CHCs to meet the health care services of the EL - A number of health indicators: + The number, and professional of health workers. 9 + CHW/CHC indicator. + Average population/doctor. + Infrastructure, medical equipment, essential drugs. - Percentage health workers have correct/not correct knowledge on health, diseases and health care for the EL in the community. - Information on infrastructure, medical equipment and medicines for the health care of CHCs. 2.3.2.3. The interest and participation of the main caregiver for the EL in the community - Percentage of the main caregivers paid attention to the EL in different forms. - Percentage of the main caregivers regularly bring the EL for health examination. - Percentage of the main caregivers was guided about health care for the EL. - Percentage of the main caregivers continued to register using health care services for the elderly at home. 2.3.2.4. The interest of the Party officers, local Government, and Unions - Percentage of officers thoroughly understands the role of Party Committees, local authorities, and Unions about HC for the EL. - Percentage of officers proposed health care measures for the EL in the community. - Percentage of officers stated the advantages and disadvantages of their local in health car for the EL. 2.4. Limitations of the research - Due to limited resources, the thesis only studied in a number of communes in Dong Anh, Hanoi, therefore, it is not too representative sample. - The thesis only mentioned the impacts of community to health care for the EL but has not found factors related to CHCs. Chapter 3 RESULTS 3.1. Characteristics, current needs, the use of health services of the elderly, and the ability of the CHCs in Dong Anh district, Hanoi 2012 to meet the needs 3.1.1. Some characteristics of the EL Among 1025 the seniors in the four selected communes, the EL women have much higher proportion than their counterparts, 63.2%, and 10 35.9%, respectively. For the structure of the age group, 707 the EL in the group 60-74 (69.0%). The majority of the elderly are literacy (96%), in which the elderly could both read, and write has the highest percentage (33.7%). Few elderly have university and college degrees, and high school degree, accounting for 2.9%, and 5.0%, respectively. 3.1.2. Current status of health and the health care needs of the elderly 3.1.2.1. Self-assessment of health of the EL There were 56.1% the EL self-reported a normal health. 22.0% the EL feel a good, and comfortable mental health. 83.7% of the EL still walk well, and only 15.9% of them had a difficulty in walking. 3.1.2.2. Health care needs of the EL After self-assessment, 52.5% of the EL reported that they had a respiratory symptom/disease, 46.1% had cardiovascular disease (of them 40.0% had HPB), psychiatric (43.7%), and musculoskeletal (37.1%). Table 3.1. Distribution of illness episodes on an elderly in the 4 studied communes Content Times getting illness/sick in the past 3 months 1 time The 2 times number of sick  3 times Uy No (n=256) Thuy Lam (n=254) Lien Ha (n= 260) Co Loa (n=255) Total (n=1025) 68.4 64.2 68.8 53.7 63.5 79.0 13.6 7.4 73.9 20.3 5.8 72.8 22.2 5.0 70.2 23.2 6.6 73.6 20.2 6.3 There were 63.5% of the EL said that they got sick in the past three month. There were 73.6%, 20.2%, and 6.3% of the EL get sick 1 time, two times, and three times, respectively. Table 3.2. Number symptoms/diseases get by the EL in the 4 communes (%) The incidence of symptoms/diseases Not detected One symptom/disease Two symptoms/diseases Three symptoms/diseases ≥4 symptoms/diseases Average number of symptoms / diseases/ 1 EL Uy No (n=256) 12.9 13.7 43.0 Thuy Lam (n=254) 15.0 12.6 12.2 Lien Ha (n= 260) 15.8 17.3 38.1 Co Loa (n=255) 17.3 24.7 35.7 Total (n=1025) 15.3 17.1 32.3 14.5 13.8 11.2 13.7 13.3 16.0 46.5 17.7 8.6 22.0 2,30 2,31 2,28 2,24 2,28 11 There were 15.3% the EL not be detected any disease. Multidiseases can be seen more clearly when a high percentage of the EL suffering from two or more symptoms (almost 70%). On average, each EL suffered 2.28 symptoms/diseases. 87.8% the EL wished to be health checked at home with a reasonable cost. There were 75.3% of the EL want to be health checked at CHCs, and 18.8% of the EL have other expectations. 3.1.3. The use of health care services of the EL 77.9% of the elderly did not health checked periodic. Many reasons for that such as not convenient, lost time (40.1%), and do not need to check (31.8%). The EL chose the hospital and general health clinic, and CHC for primary health care were 54.0%, and 32.2%, respectively. More elderly men went to the hospital, general health clinic than elderly women (58.9% and 51.5%). Meanwhile, more female elderly chose CHC and private clinics than males (33.5% versus 30.0%, and 12.2% versus 8.0%, respectively). The reasons why the elderly use health care services at CHCs are dedicated service attitude, attentive (33.0%), convenient and close to their home (32.1%), less expensive (29.4 %) ... The reasons of the EL are quite similar in the four communes. 3.1.4. Responded situation of the commune health centers for health care services for the elderly All of the CHCs have medical doctors with adequate equipment, drugs and other means (8/8 criterias). Calculating with 10 criteria followed National set of criteria for CHCs from 2011 to 2020, all of the four CHCs are met the standard (with a score from 92 to 96 compared to 100 points). Private health system is fairly developed in Uy No commune, which 20 private clinics, 15 pharmacy shops, and Co Loa commune (12 private clinics, 13 pharmacy shops), while only 6 private clinics and 11 pharmacy shops in Lien Ha commune. Thuy Lam commune has only 4 private clinics and 3 pharmacy shops. There were 520 times (5,1%), 405 times (5,8%), 413 times (5,9%), and 391 times (5,7%) the EL went to Uy No, Thuy Lam, Lien Ha, and Co Loa CHCs, respectively for health examination. 3.2. Results of the intervention model implementation, and evaluate the effectiveness of the intervention 12 3.2.1. Results of the implementation and effectiveness of health management, and health care for the elderly The categories of symptoms/diseases among the EL: heart diseases (22.5%), respiratory (18.5%), musculoskeletal (18.3%), dental (15.2%), eyes (13.8%). The proportion of cardiovascular, respiratory, urinary – genital, and gastrointestinal symptoms/diseases in the EL men were higher than that in the EL women. However, the proportion of symptoms/diseases such as endocrine diseases, musculoskeletal in EL women was higher than than that in the EL men. In average, there were 4.5 times of the EL went to the Uy No, and Lien Ha CHCs for health examination each day. Table 3.3. The effectiveness of the management, health care for the elderly at the CHCs before and after intervention Evaluated indicators Availability proportion (%) The number of the EL went to the CHCs under 1 hour Accessibility rate (%) The number of the EL had HC in the CHCs Utilization rate (%) The number of the EL had enoughprescription drugs The enough use rate (%) The number of the EL had effective treatment The rate of use effectively Intervention group before after Effecti (1) veness (2) index (EI) Control group before after EI (3) (4) 100.0 100.0 0.0 100.0 100.0 0.0 0.0 516 512 - 509 506 - - 100.0 100.0 0.0 100,0 100.0 0.0 0.0 256 474 - 251 252 - - 49.6 92.5 86.5 49.3 49.8 1.0 85.5 256 474 - 251 252 - 49.6 92.5 86.5 49.3 49.8 1.0 85.5 32 238 - 31 34 - - 12.5 50.2 301.6 12.3 13.5 9.7 291.9 Perfo mance Index (PI) (%) p1-2 <0.05; p1-3 >0.05; p3-4 >0.05; p2-4 <0.05 After intervention, the availability rate was reached 100%. All of the EL in the four communes could access the CHCs with the rate of accessibility of 100%. The rate of using enough and the rate of use effectively in the intervention group 13 increased from 49.6% to 92,5%, from 12.5% to 50.2%, respectively (p <0.05). However the two indicators in the control group increased only slightly from 49.3% and 12.3% to 49.8% and 13.5%, in turns. The activities of management, and health counseling for the EL are better in the intervention group compared to the control group, 85.5% and 291.9% (p <0.05), respectively. 3.2.2. Results of the implementation and effectiveness of communication, guidance, health counseling activities for the elderly 3.2.2.1. Results of the implementation of communication, guidance, health counseling activities for the elderly There were 78 sessions with 20 topics about health care for the EL was broadcasted on the local radio system of Lien Ha and Uy No communes after 12 month intervention. The average time for each session was 9.7 ± 0.7 minutes. Totally, 8086 pamphlets, flipcharts propaganda on common diseases in the elderly, how to prevent the diseases and so on were distributed. The intervention program organized 12 training sessions for health workers, 1 time per month, 150 minutes each. Total training time was 1800 minutes. Most of the CHWs (90.5%) and VHWs (90.1%) participated in the trainings. Direct communication: For the EL, 8 sessions for talk shows, group discussion, and practical guidance for 4068 participants (the EL) were organized, of which 2051 turns Lien Ha commune, and 2036 in Uy No commune. For the community leaders and the EL’s relatives: 1369 participants (154 times of the community leaders, and 1215 times of the main care givers) attended. Among the relatives attended the direct communication activities, 93.2% of the main caregivers were the elderly’s children. 3.2.2.2. Effectiveness of raising awareness on health care for the EL of the Party, local Governments, Unions, health staff, of he communes, and the relatives Table 3.4. The effectiveness of enhancing knowledge of VHWs, and CHWs on how to manage the EL’s health before and after intervention (%) Number of correct answers 16-18 13-15 10-12 ≤9 Control group (n=26) before(1) after PI before after PI (3) (2) (4) 13.3 50.0 275.9 11.5 11.5 0.0 20.0 50.0 150.0 15.4 15.4 0.0 10.0 0.0 100.0 19.2 23.0 19.8 56.7 0.0 100.0 53.8 50.0 7.1 p1-2 < 0.01; p1-3 > 0.05; p2-4 < 0.01; p3-4 > 0.05 Intervention group (n=30) EI (%) 275.9 150.0 80.2 92.9 14 After the intervention, 50.0% of the HWs in the intervention group answered correctly 16-18 and 13-15 questions compared to only 13.3%, and 20.0% before the intervention, therefore, the EI was 275.9% and 150.0% (p <0.01). Table 3.5. Effectiveness of improving knowledge of CHWs, and VHWs on diseases with contraindication to exercise in the elderly before and after intervention Number of correct answers 9-10 7-8 5-6 ≤5 Before intervention After intervention (n=30) (n= 30) 30.0 53.3 16.6 30.0 16.6 16.6 36.6 0.0 p <0.01 PI (%) 77.6 80.7 - The proportion HWs answered correctly the questions about the disease with contraindication to exercise in the EL from 9-10 and 7-8 questions increased from 30.0% to 53.3%, and from 16.6% to 30.0% with, respectively after the intervention with PI from 77.6% to 80.7%, the difference is statistically significant (p <0.01). Table 3.6. Effective enhance the knowledge of health staff about method PTAS, how to process initial when injured (%) Content of knowledge Exercises for EL with coronary heart disease Exercises for obese EL Exercises for arthritis EL How to manage initially when getting injury in soft parts Number of correct answers (n= 30) Before After PI intervention intervention (%) 53.3 96.6 81.2 53.3 46.7 93.3 90.0 75.0 92.7 40.0 100.0 150.0 p < 0.01 Knowledge on physical activity, and how to manage the injury EL before and after the intervention were increased with PI from 75.0% to 150.0%. The difference was statistically significant (p <0.01). Table 3.7. Effectiveness of raising the interest of the commune Party, local government, Unions about health care for the elderly before and after intervention 15 Content Before (n= 18) n % After (n= 18) n % 1. Understand the role of Party committees 1.1. Promulgation resolutions, directions, 9 50.0 18 100.0 plans and guidelines for the EL health care 1.2. Funding for CHCs for the EL health 11 61.1 18 100.0 1.3. Funding for health care for the EL 11 61.1 18 100.0 poor, disabled, loneliness, and helpless 1.4. Allocate commune budgets for health 13 72.2 18 100.0 care for the elderly 1.5. Organize health clubs for the elderly 15 83.3 18 100.0 2. Organize health examination for the elderly in the community 2.1. Organize of periodic HE for the EL 15 83.3 18 100.0 2.2. Organize of HE at home for the EL 11 61.1 18 100.0 2.3. Organize health communication, health counseling 11 61.1 18 100.0 for the EL 3. Propose health care policies for the elderly 3.1. Supply free health insurance card for the EL 15 83.3 18 100.0 3.2. Subsidies for the EL who are poor, 14 77.7 18 100.0 disabled, loneliness and helpless 3.3. Workers are entitled to take care of 7 38.9 11 61.1 fathers/mothers who is the elderly getting ill 4. State the advantages and disadvantages of local health care for the elderly 4.1. Advantages Ordinance of the EL, Law of the EL and the 6 33.3 18 100.0 documents of the Party, Government about the EL - The attention of the Party committees, 10 55.6 18 100.0 local Governments, Union to the EL - The enthusiasm, active of the Commune 14 77.8 18 100.0 EL Association - The enthusiasm, the ability to take care the EL of 9 50.0 18 100.0 the CHCs - Increasing awareness of family, and 7 38.9 18 100.0 relatives of the EL for health care 4.2. Disadvantages - Not mobilize the participation of the 17 94.4 18 100.0 political system - Lack of funding for health care activities 17 94.4 18 100.0 for the EL - Living environment, living for the 14 77.8 18 100.0 elderly is not paid attention - The attention and care for the poor, disabled, loneliness EL have not much 14 77.8 18 100.0 paid attention - Families having the EL have many difficulties 13 72.2 18 100.0 p < 0.01 PI (%) 100.0 63.7 63.7 38.5 20.0 20.0 63.7 63.7 20.0 28.7 57.0 200,3 79,9 28,5 100,0 157,0 5.9 5.9 28.5 28.5 38.5 16 100% of local officers understand the role of Party committees, local government, Unions to take care the elderly, propose measures for the EL’s health care in the community. The interviewees perceived the advantages and disadvantages of health care for the EL in the communes. 100% interviewees agree with the comment that provide free insurance cards for the EL, and subsidies for the poor, disabled, loneliness, and helpless elderly . PI ranges from 5.9% to 200.3%. Table 3.8. Effective ness of increasing the attention of the main caregivers for the EL before and after intervention (%) Intervention group (n= 506) before after PI (1) (2) Criteria Pay attention, spend time to take care the EL Attend the talk shows about health care for the EL Collaborate with HWs in healthmanagementfortheEL Contribute resources for the EL’s health care Control group (n= 505) before after PI (3) (4) EI (%) 22.7 92.5 307.5 20.4 21.2 3.9 303.6 22.3 85.0 281.1 19.8 20.8 5.0 276.1 18.4 79.8 333.6 18.0 18.4 2.2 331.4 16.6 72.5 336.7 17.8 18.0 1.1 335.6 p1-2 <0.05 ; p1-3 > 0.05; p2-4 <0.05; p3-4 >0.05 The intervention has evoked the interest of family members to health care for the EL in the intervention group by the actions as spending time ta attend the talks (increase from 22.3% to 85.0%), spending time to HC the EL (increasing from 22.7% to 92.5%), contributing to economics resources for the community (increasing from 16.6% to 72.5%). The differences were statistically significant (p<0.05). PI from 281.1% to 336.7%. Table 3.9. Effectiveness of improving the knowledge of the elderly about the purpose of taking yoga and physical activity before and after intervention (%) Purposes Keep and enhance the health For entertainment For disease treatment Follow other poeple Do not know Intervention group before after PI (1) (2) Control group before after PI (3) (4) EI (%) 66.3 100.0 50.8 65.7 70.1 6.7 44.1 43.0 91.4 112.6 51.0 52.2 2.4 110.2 28.9 83.6 189.2 30.4 35.4 16.4 172.8 20.5 53.3 160.0 22.5 20.3 8.4 00.0 7.8 7.1 p1-2 <0.05; p1-3 > 0.05; p2-4 <0.05; p3-4 >0.05 9.7 9.0 150.3 - 17 The proportion of the EL have good knowledge about the purpose of physical activity in the intervention group increased from 28.9%66.9% to 83.6% - 100% before and after the intervention, higher than that among with the control group with PI ranging from 50.8% -189.2%. 3.2.2.3. The results and effectiveness of the outdoor health club (OHC) performance Table 3.10. Number of the EL participated in OHC before and after intervention Before intervention Evaluation index Number of the EL participated in OHC Percentage of the EL participated in OHC After intervention Lien Ha (n= 260) Uy No (n=256) Total (n=516) Lien Ha (n=258) Uy No (n=254) Total (n=512) 82 60 142 250 248 499 31.5 23.1 27.5 96.9 97.6 97.5 PI (%) - 254.5 p <0.01 After intervention the number of the EL to participating the OHCs raised from 27.5% to 97.5%, PI is 254.5%. Most of subjective feelings of the EL since to participate in the OHCs were lower than before the intervention, the rate decreased from 70.8% to 95.7%. In particular, subjective feelings with largest decline were tired (95.7%), backache (93.4%), feeling sleepy at daytime (88.9%). Table 3:11: The health status of the EL after 12 month intervention Intervention group Control group (n=512) (n=506) Subjective feelings before after before after before after (1) (2) (1) (2) (1) (2) Good 15.7 32.6 107.6 13.3 14.8 11.2 Normal 56.9 66.2 16.4 55.2 56.1 1.6 Physically Weak 26.1 1.2 95.4 30.3 28.2 6.9 Very weak 1.1 0.0 100.0 1.2 0.9 25.0 Comfortable, pleasant 24.4 45.3 85.6 19.6 19.8 13.3 Normal 51.2 52.9 3.3 60.9 65.4 1.2 Mentally Uncomfortable 20.5 1.8 91.2 17.3 13.6 21.3 Worry, sadness 3.9 0.0 100.0 2.1 1.2 42.8 p1-2 <0.05; p1-3 > 0.05; p2-4 <0.05; p3-4 >0.05 EI (%) 96.4 14.8 88.5 75.0 72.3 2.1 69.9 57.2 18 After 12 month participating the outdoor clubs, the health of the EL has improved significantly. The number of healthy people has significantly increased compared to before the intervention, and with the control group, EI is 59.4% . The difference is statistically significant (p <0.05). The proportion of EL felt comfortable, agreeable increased (PI = 85.6%). A few EL felt worried, depressed. Only 1.8% of the EL felt uncomfortable, an decrease of 20.5% compared to before the intervention. Chapter 4 DISCUSSION 4.1. Current needs, the use of health care services by the elderly and the ability to meet of CHCs in Dong Anh district, Hanoi 2012 4.1.1. Situation of health and the needs to health care of the elderly The self-assessment of the health situation of the EL are still subjective by the different perceptions and adaptability of each person. A big proportion of the EL still did not feel mentally comfortable. This is maybe the urbanization life has accounted for most of the time of the families. It is, therefore, the family members could not pay as much attention to the EL as before. On the other hand, general psychology EL is easy unhappy, guilt, fear itself as redundant as well as the burden for their families. In this study, the majority of the elderly can walk, and having normal activities by themself (83.7%). Other studies also showed similar results. This suggests that a large proportion of the elderly in the community still walk independently, self-serve, and able to contribute to their families and society. The improving life also made significant impacts to the disease patterns of the EL. The proportion of the healthy EL accounted for only 15.3%. Multi-disease pattern shown since the number of the EL suffering from two symptoms/diseases accounted for the highest percentage (32.3%), followed by 4 or more symptoms/diseases (22.0%), one symptoms/diseases (17.1%) and 3 symptoms/diseases (13.3%). On average each EL suffered 2.28 diseases. This result is consistent with previous studies on diseases among the EL. Thus, it is noted that aging is not a disease but due to many factors can make the EL easy to get diseases. It is, therefore, making the health of the EL diminished. It is not only a challenge for the health system but also for the whole society. 19 4.1.2. Factors related to the health of elderly There are many related factors to the health of the EL such as gender, age, educational level, current occupation. However the lifestyle, relatives, families, and social of the EL are the main factors impact to the EL’s health. The healthy lifestyles such as healthy eating, physical activities.... are very important to keep a good health for the EL. Having good habits is an effective, economic measure to keep a good health. Therefore, in order to care, and improve health for the EL, all of the affected factors need to be considered. This should be coordinated by the EL themselves, their families as well as the interest of the Party committees, Government, Unions at all levels. 4.1.3. The use of health care services of the elderly Research on the use of HC services and the factors that impact to the decision to choose the services of the EL has been conducted widely. This is also the key issue to develop a suitable health service, and meet the needs of health care of the EL. Another important thing is the health service users will have impacts on the health service delivery system, but not by the providers. Therefore, in order to improve the efficiency of health service delivery system for the EL, it is needed to know the needs, aspirations, and changing trends in the way to use the services of the EL in community. However, the current situation shows that health sector has not received a proper attention from the Government. Therefore, it has not created a believe by the people. The evidence of this is not many the EL go to the CHCs for HE. The main reasons of coming are convenience, close to home, do not need to wait long ... 4.1.4. The ability to meet the health care services of CHCs CHCs is the closest level to the community. It is the primary level that people can contact with the health system to detect health issues. Although the Vietnam Party and State have issued the mechanisms and policies to strengthen, and develop the primary HC network, however, there are still many CHCs lack of HWs, facilities, and equipment in providing health service, primary HC for people, especially for the EL. 20 The development of the private health sector has created a healthy competition to promote the development of the State health system in general and CHCs in particular. These are favorable conditions for people to access to various types of suitable quality health services at low cost. Based on the social-economic characteristics, the needs, resources and ability to meet of the CHCs in Dong Anh district, Hanoi, we developed and piloted a model namely “the community-based model to manage, consult, and care for the health of the elderly", and initially got some achievements. 4.2. Develop and pilot the community-based model to manage, consult, and care for the health of the elderly 4.2.1. Develop the intervention model Currently, many HC models for the EL has been applied in many parts of the country. However, these models have many particular characteristics, depending on the economic circumstances of each locals, and they only serve one certain group such as the poor EL, loneliness, no one to rely or the EL with good economic conditions. Therefore, to ensure that all of the EL to be health cared, we developed the model "the community-based model to manage, consult, and care for the health of the elderly”. The model has been conducted at 2 communes, Uy No and Lien Ha commune, Dong Anh District, Hanoi with different contents, including health management, HC for the EL; health communication, guidance, health counseling and OHCs establishment. 4.2.2. Results and effectiveness of the model 4.2.2.1. Results and the effectiveness of health management, and HC for the elderly Through the health management and health examination for the EL, the CHCs will detect and prevent on time new developed disease. This will contribute to improve the quality of life and lengthen the life expectancy for the EL. To evaluate the effectiveness of health management, and HC for the EL, we used indicators of community-based monitoring (CBM). In the intervention group, the utilization rate was higher than before the intervention and control group compared with EI is 85.5% (p <0.05). The utilize enough rate, the effective use rate also increased from 49.6% to
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