基于循证实践方法的老年人口健康干预研究
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摘要
人口老龄化是当今全球人口发展的趋势。随着人口老龄化加剧,如何使得老年人口在衰老过程中保持较高健康水平引起学术界的广泛关注。影响和干预老年人健康的因素是错综复杂,为什么有的老人虽然患有多种慢性病却能积极生活长寿直到逝世,而有的老人却被一病拖垮,给自己、家人、社会带来巨大痛苦和负担?哪些个人、家庭或社会的干预措施既经济,操作性又强,还有益健康长寿?人类如何实现积极健康老龄化这一目标?这不只是医学与生物学的范畴,同样是人口学与社会学等领域需要共同面对的难题。不言而喻,个体的老龄化组成了社会的老龄化。老年人在生理、心理、社会完好性的问题是加剧人口结构老龄化并引发社会、经济等相关问题的本因。因此,本研究聚焦于讨论老年人口健康问题的干预措施,以缓解社会老龄化问题。
     目前,针对老年人口健康的干预措施多种多样,评价方法也各有千秋,然而,循证实践(evidence-based practice)作为一种国际上通行的生产和评价干预证据的研究方法,被认为是可靠的科学证据,吸引了越来越多的中国政策制定者和不同领域研究者的目光。本研究立足于循证实践理论,开展老年人口健康干预研究。具体而言,文章共分为六章。
     第一章是导论。导论部分提出了本研究的背景、意义和主要问题,阐述了研究的主要内容,介绍了研究使用的方法,总结了可能的创新点和局限性。第二章是研究基础与文献综述。阐述了相关概念,对基于健康老龄化的老年健康研究状况和基于循证实践的老年健康研究现状进行了梳理。此外,分别从老年健康的研究领域,研究范式和研究的拓展性等几个方面对中外文献进行述评,指出本研究的可能贡献所在,以此作为深入研究的基础。第三章是基于循证实践方法的老年人口健康干预的理论分析。通过界定老年健康干预的概念,总结个体和群体老年人口健康干预的理论基础,分析了老年人口健康干预的内容和作用机理,提出了基于循证实践方法的研究框架,进而引申出循证实践思想对研究科学化的启示。第四章是证据搜寻和评价环节。在这部分,以社交孤立预防措施为例,进行了老年人口健康干预的系统评价,评估了针对老年人社会孤立问题干预措施的有效性。本章研究运用系统评价方法,系统检索10个国内外数据库,例如Cochrane Library和中国期刊全文数据库等,以及尚未公开发表的学位论文。从784个原始研究中筛选符合既定纳入标准的随机对照试验,通过Cochrane偏倚风险工具对纳入试验进行质量计分,运用归纳描述方法评价干预措施的疗效。评价指标包括结构性社会支持、功能性社会支持和孤独感3个维度。结果发现,纳入的20项干预老年人孤立的随机对照试验(n=3104),18项研究为低等或中等偏倚风险,其中12项研究至少在1个维度呈现出对社会孤立状态的改善效果,9例团体干预和3例个体访谈干预呈现改善效果。本研究提示对存在社会孤立问题的老年人,采取团体式或面对面式干预措施有助于改善其生活质量。并在此基础上,探讨公共卫生决策中对系统评价研究方法的认识误区,希望可以帮助决策者使用和正确理解系统评价的作用,协助决策过程,提高决策效力。第五章是证据的实施和应用环节。研究了个体健康干预对四川省老年人口行为和生命质量的影响。这一章以成都市金牛区九里堤街道北路社区养老服务中心和南充市芦溪县爱老养老服务站为城乡研究现场,通过定量和定性相结合的研究方法分析了城乡干预组和对照组老年人群的基本社会人口学状况及健康行为情况。在城乡社区分别开展了6个月的个性化健康干预试验,最终从行为生活方式改变及SF-36评分改变等方面对个性化健康干预效果进行了评价。研究为探索老年人群生命质量及其影响因素提供了科学依据,并为今后健康老龄化工作积累了宝贵的经验。最后在第六章基于研究结论提出了推进老年人口健康干预的对策和建议。提出基于循证实践方式,通过各层级部门间五步骤的分工协作,共同建立老年人口健康干预统筹协调机制,并提出完善基于循证实践方法的老年人口健康干预政策和制度的相关建议。
     以上六章构成了本文的六个部分,即问题提出、研究基础、理论分析、证据评价、证据实践、研究启示和结论对策。这六个部分有紧密的逻辑联系,逐层深入,分别回答了“为什么要进行老年人口健康干预研究?”、“什么是老年人口健康干预研究?”、“基于循证实践的老年人口健康干预的理论依据是什么?”、“如何通过循证实践方式进行老年人口健康干预的证据评价和实践?”、“这样的新研究范式可以为政策建议提供怎样的指导?”等问题。本研究的最大创新点在于采用循证实践研究理念和方法,首先对干预老年健康的各类证据进行系统评价,再运用随机对照试验方法进行城乡老年人口健康干预实证研究,以此设计、生产、存储、推广符合实际需要的高质量研究证据,为中国的健康老龄化过程提供现实参考依据,并据此提出循证实践方法对人口学研究的启示。不足之处,在研究过程的质量控制方面,本研究虽然严格按照COCHRANE及CAMPBELL手册操作执行,并取得CAMPBELL数据库SOCIAL WELFARE方法学组授权,但是在使用系统评价得出的证据的时候,由于研究条件的限制,并非完全按照证据内容实施,将社交孤立干预扩展为了健康生活习惯干预。在系统评价方面,研究人员主要为本人,并无专门评价小组,虽然通过HULUK和IRIS CHI对争议数据的讨论,降低了主观偏倚,但仍然存在一定的证据选择偏倚。同时,由于通过社会因素探讨老年人口健康干预的证据,相对于医学、卫生学、心理学等少很多,可供纳入的证据数量不多,故存在一定的纳入偏倚,有待进一步研究。所以该研究主要从方法学对未来研究有参考价值,证据使用者请结合自身实际情况慎重参考本研究的其它结果。
The aging is now tendency of the global population.With the tendency, it arouses widespread academic's interest on making the elderly health in aging process. Factors that affect and interfere with elderly healthy are complex. Why some people with chronic diseases could have been able to live actively until death, but some other people who were ill and collapsed, have caused great pain and burden to themself, family and society? Which interventions are not only economic, operational, but also better for health and longevity? How does the humanity achieve the goal of positive aging? This problem is not only in medicine and biology area, but also in demographic and social sciences. Physical, mental and social integrity of the elderly problem always lead to social, economic and other related issues. Therefore, this study focuses on interventions for the health problems of the elderly population to alleviate social aging problem.
     At present, there are various measures and evaluations for elderly health intervention, however, Evidence-based practice as a common worldwide methodology of evidence production and evaluation, which is considered a reliable scientific way and attracting more and more Chinese policy-makers and the different areas of the researchers' eyes. This research is based on the theory of evidence-based practice, and carrying out health intervention in elderly population. Specifically, this research consists six sections.
     Section1and Section2are the research foundation, which briefly introduces the research background and purpose, contents, methodologies, innovations, limitations and the theory basis in the research, defines the fundamental concepts and reviews the related researches. Section3reviews and analyzes the theories and content of elderly health intervention and evidence-based practice, and proposed theoretical framework of the research. Then, it arises out the scientific insight for population health behavior intervention research by evidence-based practice thinking. Section4is the evidence search and evaluation, In this section, it assesses the effectiveness of the interventions targeting elderly social isolation. A systemic review was conducted through searching10relevant databases, such as Cochrane Library, China National Knowledge Infrastructure and unpublished thesis. The randomized controlled trials (RCTs) were screened from784original studies according to set inclusion criteria, and assessed with the Cochrane risk of bias tool. Then narrative synthesis was used to summarize and interpret the interventions. The evaluation indices included3dimensions, namely, structural social support, social support and loneliness. Resultly,20RCTs (n=3104) were included in the review,18RCTs were at low or medium risk of bias,12studies reported promotion as least in one dimension,9group intervention and3individual interview intervention reported improvement. This research focuses on each real example, trying to clarify these misunderstandings and fallacy, promoting the development of the systematic review in the field of health decisions. Section5is the implementation and application of evidence. Study on the effect of the individual health behavior intervention on the elderly in Sichuan Province. We take Chengdu City Jinniu District jiulidi north Road community elderly service center as urban sample and take the Nanchong city Luxi love elderly service station as rural sample. We have carried out6month-long personalized health intervention experiments in the urban and rural sample spot, finally carried on the appraisal to the personalized health intervention effect by behavior questionnaire and SF-36.Finally in the section6, we promote strategies and recommendations of elderly population health intervention basing on evidence-based practice.
     This research has some innovation including theoretical analysis, technical method, and structural consideration. However, there are several limitations in this research. When we use of the evidence from systematic review, due to the limitation of research conditions, the intervention content was not only focus on social isolation but also some other health behaviors. Also, there may be certain inclusion bias and selection bias. Some future improvement has to be made based on current research.
引文
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