美国卫生公平社会决定因素分析与对策

卫生不公平是当前全球普遍面临的重大课题,但导致不同国家卫生不公平的原因又各有不同。本文对影响美国卫生公平的社会决定因素进行了分析,并对美国政府及相关机构采取的相应措施及难点进行了阐述。造成美国卫生不公平的主要原因在于种族及阶级歧视、贫富不均、就业及生活环境、生活习惯等方面存在差异;采取的相应措施包括成立促进卫生公平的相关组织,研究并揭示导致卫生不公平的社会决定因素,唤醒公民主动追求公平的意识,为决策者提供改善公平性的政策建议。最后提出了对我国的启示,如提高公众对卫生公平性的认识、缩小贫富差距、杜绝种族歧视、加强劳动保护和健康管理、保护环境等。     

中国大陆城市新移民健康公平的社会决定因素研究

目的 明确中国大陆城市新移民健康公平现状及其社会决定因素,为进一步改善当前现状提供理论依据。方法 以健康社会决定因素的分层模型为框架展开文献回顾并进行整理分析,梳理影响城市新移民健康公平的相关因素。结果 目前我国大陆城市新移民健康公平状况尚存在一些特殊问题,受到包括生存环境、社会经济地位、社会保障及其他相关政策因素的影响。结论 在城市新移民融入城市的进程中,政府应积极改善其生存环境,保障其合理收入以缩小贫富差距,同时落实各项保障政策,合理配置卫生资源,逐步实现健康公平,使其更好融入城市。     

人口老龄化对卫生健康水平的影响研究

目的:模拟人口老龄化背景下卫生健康指标的变化趋势,提出不同的应对策略。方法:构建动态随机一般均衡模型和卫生指标估算程序,采用基于贝叶斯估计的模型比较法及比较静态分析法,估算不同老龄化程度下的卫生健康指标值;通过调整相应的参数,模拟提高医保报销比例和实行老龄人口健康管理的政策效果。结果:在人口老龄化程度不断加深的过程中,社会医疗负担不断增长,卫生筹资公平性和社会福利水平呈先恶化后好转的趋势。政策模拟结果表明,提高医保报销比例会提升整体健康水平和福利水平,但可能增加社会医疗负担和健康不公平;实行老龄人口健康管理会在维护全民健康的同时,避免社会医疗负担和健康公平性的恶化。结论:加快构建面向预防、健康管理的医疗体系,推进“健康老龄化”建设,同时加强对医保基金使用的监管,提高医疗保障政策的针对性和实效性。     

欧洲改善健康公平性的主要措施

康不公平受到众多因素的影响,卫生系统可以通过改变卫生服务模式和加强与其他部门的合作来干预健康的社会决定因素,以缓解社会健康不公平现象。在欧洲,通过整合卫生资源,拓展卫生服务领域,以及加强监督管理等措施,改变了公共卫生服务模式,促进了健康公平性的改善。     

数字健康公平：理论视角与影响因素

数字时代推动卫生健康现代化和促进卫生健康领域共同富裕,不可回避健康公平的问题。数字健康公平包括基于创新扩散理论的利用公平,以及基于数字正义理论的算法公平。数字健康公平的影响因素包括4个层面：个体层面（包括数字健康信念、数字健康素养、数字健康信任）、人际层面（包括人际传播和群体偏见）、社会层面（包括基础设施、大众传播、法治监管）和系统层面（包括数据质量、算法标准、结果审查）。     

关于健康社会决定因素研究的博士及博士后人才培养案例

全球特别是中低收入国家的健康及健康不公平问题日益严峻,这些国家缺乏健康社会决定因素研究能力,无法有效地参与国家和国际卫生政策的改革,实现健康公平。面对这一问题和挑战,中低收入国家亟需进行医学教育的创新和改革,培养一批从事健康社会决定因素研究的人才。在此背景下,“加强亚洲地区健康社会决定因素研究能力（Asian Regional Capacity Development for Research on Social Determinants of Health,ARCADE-RS-DH）暠应运而生。该项目通过国际化强强合作,应用混合教学模式,培养一批在健康社会决定因素研究领域学有所长的博士和博士后人才,以提高中低收入国家在健康社会决定因素领域的研究能力,力图解决当前的健康不公平问题。对该项目的研究背景、定位和实施、教学创新等方面作了简要概述。     

健康的社会决定因素与慢性病防治

健康的社会决定因素是指在那些直接导致疾病的因素之外,由人们居住和工作环境中社会分层的基本结构和社会条件所产生的影响健康的因素,它们是导致疾病的＂原因的原因＂。WHO健康社会决定因素委员会建立了完整的＂健康的社会决定因素＂概念框架,并提出了三条基本行动策略。健康的社会决定因素对慢病的影响举足轻重,并通过生理、行为方式途径、精神因素途径、卫生服务利用和保障水平的不同发挥作用。社会决定因素对慢病的影响涉及方方面面,因此慢病综合防治不应仅仅停留在个人危险行为干预层面,而应从健康的社会决定因素角度出发,将提高人民健康水平、促进慢病防控的目标融入社会所有的政策之中,促进多部门协作,保持政策一致性,从而更好地对慢病进行防控。     

老年疾病负担与公共卫生服务

随着人口老龄化在世界范围蔓延,我国的老龄人口健康问题引起了社会的广泛关注。老年人面临的疾病负担成为卫生服务研究中的重要内容。老龄人口作为健康领域中的弱势群体,在生理、心理和社会适应性方面都弱于青壮年,这就对我国公共卫生服务提出了更高的要求。     

控制健康决定因素，提高人群健康水平

随着社会经济的不断发展,我国居民健康水平得到了长足的进步。但与此同时,健康不公平现象不是减少了,而变得更加突出。例如改革开放以来我国城乡之间、不同地区之间健康不公平不是缩小了,而是有不断增加的趋势。随着全球化、城市化、老龄化、环境污染的恶化和全球气候变暖,影响我国人民健康的决定因素将变得更加复杂。如何在新的时期,应对这些复杂多变的健康决定因素,提高人群健康水平,     

关于中国建立特困人口医疗救助制度的必要性探讨

通过对贫困人口的健康状况,健康公平状况,健康制度享有情况以及其对实现卫生目标的作用和意义等方面的分析讨论,并在与国外有关情况的对比分析的基础上,提出了在中国建立特困人口医疗救助制度的建议。认为建立这样一种制度将有助于我国社会经济的健康发展,并进一步推动扶贫工作的开展,更为重要的是,它对于改善我国人口的健康状况,改善卫生公平性以及提高卫生部门的效率具有十分重要的意义。它是确保我国实现其卫生目标的最佳策略选择之一。     

多元社会参与及家庭支持对中国老年人心理健康的影响研究

目的：了解不同社会参与类型和家庭支持对老年人心理健康的影响及交互作用,为促进老年人心理健康提供决策依据。方法：基于2018年中国老年健康影响因素跟踪调查（CLHLS）数据筛选获得12 686名老年人,使用描述性分析、Pearson相关性检验、二元logistic回归模型研究不同社会参与、家庭支持特征的老年人心理健康现状及相关性,分析其对老年人积极、消极情绪的影响,探讨多元社会参与类型间的交互作用。结果：有社会参与和家庭支持的老年人心理健康较好的发生比高达5.72%~17.50%;休闲娱乐型、社会交往型社会参与及与家人同住对老年人心理健康有显著促进效应,且该两类社会参与间存在显著交互作用,家务型社会参与则对心理健康有负向影响。结论：不同类型社会参与对老年人心理健康的影响存在差异和部分互替性,与家人同住为代表的家庭支持能显著改善老年人的心理健康水平,应鼓励老年人更多地参与社会活动、与家人共同居住,以提高老年人的积极情绪,降低消极情绪的发生风险。     

Use of home care services by elderly Chinese immigrants

Using the Anderson Service model, this study examined the level and predictors of using selected home care services by elderly Chinese immigrants in Canada. Data from 1,537 randomly selected Chinese immigrants aged 65 years and older were used. Only 5.2% of participants reported using home care services. Being older, living alone, having a post-secondary education, immigrating from Hong Kong or Southeast Asia, having a higher level of agreement with Chinese health beliefs, higher social support, and poorer physical and mental health were predictors for home care service use among elderly Chinese. The probability of using homecare services lessens with increased self-rated financial adequacy. These findings point to the need for service providers to address the gap in use of home care between elderly Chinese immigrants and overall elderly Canadians through promoting appropriate use of home care among elderly Chinese immigrants.     

老年人社会经济地位对健康的影响机制研究——兼论生活方式、公共服务和社会心理的中介效应

社会经济地位差异会带来老年人健康的不平等,社会经济地位的弱势对老年健康产生不利影响,但生活方式、公共服务和社会心理因素可在一定程度上弱化社会经济地位对老年健康的直接影响。基于2014年中国老年健康影响因素跟踪调查(CLHLS)数据,利用有序Logistic回归模型实证分析了社会经济地位对老年人健康状况的影响,并考察了生活方式、公共服务和社会心理维度变量的中介效应。研究发现:社会经济地位越高,老年人的自评健康、生理健康和精神健康状况越好;体育锻炼、食用水果和居住安排等生活方式变量有利于缓解社会经济地位弱势对老年健康的负面影响;医疗服务可及性在社会经济地位与老年健康的关系中具有显著的中介效应,但社区服务丰富性的中介效应不明显;生活满意度和社会参与度也能缓解社会经济地位弱势对健康造成的不利影响。改善老年人的健康状况不仅需要改变部分老年群体的社会经济地位弱势状态,也应该倡导健康的生活方式、提高公共服务水平和促进老年社会参与度。     

医养结合背景下城乡社区老年健康管理服务供给及效果研究——来自“中国老年健康影响因素跟踪调查”的证据

本文利用“中国老年健康影响因素追踪调查(CLHLS)”十年的数据,实证考察了医养结合背景下,城乡社区老年健康管理服务供给及效果。结果发现,尽管我国社区健康管理服务的供给水平不断提升,但总体水平较低,城乡差异仍然突出,特别是“精神慰藉”等心理健康服务仍然不足;提高社区健康管理服务有助于降低城乡老人发生大病、认知受损及负面情绪等风险,同时也有助于提高老年人特别是农村老人的生活满意度。因此,要特别注重提高服务供给的城乡均等化水平,同时也要有针对性地增加与促进老年精神及认知健康相关服务内容。     

The Impact of Health Insurance on Health Outcomes and Spending of the Elderly: Evidence from China's New Cooperative Medical Scheme

This paper investigates the effects of China's New Cooperative Medical Scheme (NCMS) on health outcomes and healthcare expenditure of the elderly in rural China, using panel data from the 2005 and 2008 waves of the Chinese Longitudinal Healthy Longevity Survey. We employ a strategy that combines propensity score matching with a difference‐in‐differences approach to address selection bias. Results show that the NCMS has significantly improved the elderly enrollees' activities of daily living and cognitive function but has not led to better self‐assessed general health status. We find no significant effect of NCMS on mortality for the previously uninsured elderly in NCMS counties, although there is moderate evidence that it is associated with reduced mortality for the elderly enrollees. We also find that the elderly participants are more likely to get adequate medical services when sick, which provides a good explanation for the beneficial health effects of NCMS. However, there is no evidence that the NCMS has reduced their out‐of‐pocket spending. Furthermore, we also find that low‐income seniors benefit more from NCMS participation in terms of health outcomes and perceived access to health care, suggesting that the NCMS helps reduce health inequalities among the rural elderly. Copyright © 2014 John Wiley & Sons, Ltd.     

Advancing health equity through social care interventions

Objective

To use evidence on addressing racism in social care intervention research to create a framework for advancing health equity for all populations with marginalized social identities (e.g., race, gender, and sexual orientation). Such groups have disproportionate social needs (e.g., food insecurity) and negative social determinants of health (SDOH; e.g., poverty). We recommend how the Agency for Healthcare Research and Quality (AHRQ) could advance health equity for marginalized populations through social care research and care delivery.

Data Sources and Study Setting

This commentary is informed by a literature review of social care interventions that were affiliated with healthcare systems; input from health equity researchers, policymakers, and community leaders attending the AHRQ Health Equity Summit; and consensus of the authors.

Principal Findings

We recommend that AHRQ: (1) create an ecosystem that values research on SDOH and the effectiveness and implementation of social care interventions in the healthcare sector; (2) work with other federal agencies to (a) develop position statements with actionable recommendations about racism and other systems that perpetuate marginalization based on social identity and (b) develop aligned, complementary approaches to research and care delivery that address social marginalization; (3) advance both inclusive care delivery and inclusive research teams; (4) advance understanding of racism as a social determinant of health and effective strategies to mitigate its adverse impact on health; (5) advance the creation and scaling of effective strategies for addressing SDOH in healthcare systems, particularly in co-creation with community partners; and (6) require social care intervention researchers to use methods that advance our understanding of social health equity.

Conclusions

AHRQ, as a federal agency, could help advance health equity using a range of strategies, including using the agency's levers to ensure AHRQ stakeholders examine and address the unique experiences of socially marginalized populations in SDOH and social care intervention research.     

老年居家卫生服务模型研究

目的：改善老年人的健康状况、提高其卫生服务可及性。方法：采用了专家研讨会和概念建模的方法。结果：老年卫生服务的目标是实现其健康老龄化和积极老龄化，途径是为他们提供连续的、全方位的、没有灰色带的、能够提高他们独立生活能力的综合性服务。老年居家卫生服务模型主要包括4个微观系统领域：自我管理支持、决策支持、递送系统设计和临床信息系统；服务内容包括初级卫生保健服务和社会服务两部分。结论：居家卫生服务对于提高老年人卫生服务可及性、提高其独立生活能力、改善其健康状况具有很强针对性。     

贵阳市老年人主要健康问题及对策研究

目的：探讨贵阳市老年人主要健康问题和解决对策。方法：于1997年3月对贵阳市威清社区老年人健康状况进行了问卷调查。结果老年人主要健康问题为慢性非传染性疾病患病率高、ADL丧失率高,由于社会经济地位偏低导致的心理和社会健康损害以及在卫生服务需求上的高需要和低要求状况。结论：提出开展以健康教育为核心的社区健康促进与社区 疗保健服务相结合的老年社区卫生服务模式是解决贵阳市老年人健康问题的重要途径,并提出了目前贵阳市开展社区卫生服务存在的主要障碍和解决建议。     

Immigrant health,place effect and regional disparities in Canada

The paper addresses a critically important area in Canadian immigration and health from both a social and a spatial perspective. It employs multilevel and contextual approaches to examine the social determinants of immigrant health as well as the place effects on self-reported health at a regional and neighborhood scale. The data come from the raw microdata file of the 2005-10 Canadian Community Health Survey (a random national health survey) and the publicly available Canadian Marginalization index based on the 2006 Census. Three populations are compared: Canadian-born, overall foreign-born, and Chinese immigrants. The results suggest various degrees of association between self-reported health, individual and lifestyle behavioral characteristics, and neighborhood material deprivation and ethnic concentration in census tracts. These factors contribute differently to the reported health of Chinese immigrants, Canada's largest recent immigrant group. A healthy immigrant effect is partially evident in the overall foreign-born population, but appears to be relatively weak in Chinese immigrants. For all groups, neighborhood deprivation moderately increases the likelihood of reporting poor health. Ethnic concentration negatively affects self-rated health, with the exception of the slight protective effect of Chinese-specific ethnic density in census tracts. The multilevel models reveal significant area inequalities across Census Metropolitan Areas/Census Agglomerations in risk of reporting unhealthy status, with greater magnitude in the foreign-born population. The vast regional variations in health among Chinese immigrants should be interpreted carefully due to the group's heavy concentration in large cities. The study contributes to the literature on ethnicity and health by systematically incorporating neighborhood contextual effects in modeling the social determinants of immigrant health status. It fills a gap in the literature on neighborhoods and health by focusing on ethnically disparate groups rather than on the general population. By revealing regional disparities in health, the paper adds a spatial perspective to the work on immigrant health.