社区医生首诊服务动力形成机理及治理逻辑研究

社区医生首诊服务能力及可持续发展动力无疑是当前推进基层首诊及分级诊疗制度建设的关键要素。本文通过对"动力"相关概念及发展的逻辑综述,并结合当前我国社区首诊服务以及社区医生角色特质分析,提出并界定了社区医生首诊服务动力的概念及内涵,在重点对构成社区医生首诊服务的引力、支持力、推力、压力等外在动力和由职业认同、自我效能和成就动机三维度形成的内生动力以及相互作用关系规律论证阐述的基础上,构建了以形象和直观为特征的社区医生首诊服务动力形成机理,为当前科学治理和提升社区医生首诊服务动力以及有效推进社区首诊制提供了可供探究的逻辑路径和依据。     

基层医疗卫生改革与发展逻辑框架及评价指标

目的建立一套基层医疗卫生改革与发展逻辑框架及其评价指标,指导各地精准定位基层卫生发展核心问题、分析问题产生的原因。方法采用文献综述、专家研讨会等方法制定逻辑框架及评价指标,并以北京市为例进行案例研究,进一步完善逻辑框架和评价指标。结果本研究将基层卫生综合改革内容归为三个大方面:"工作能力"、"机构活力"和"服务引力",其中"工作能力"是基础,"机构活力"是前提,"服务引力"是根本,从而提出基层医疗卫生改革与发展的"三力平衡模型"逻辑框架以及20个核心评价指标。结论 "三力平衡模型"的逻辑框架及其评价指标为各地分析基层医疗卫生改革和发展提供整体观的视角,有利于指导各地精准定位基层卫生综合改革的核心问题及其原因,从而采取更有针对性的措施。     

社会大卫生——全球卫生工作发展的一个里程碑

社会大卫生是总结建国以来卫生工作成功经验的结晶,是全球卫生发展的又一里程碑.它把预防医学推向社会预防新水平,是我国对国际卫生的贡献.与WHO认为防治心脑血管病、癌症和儿童保健革命的"社会决定论"相符合,也与公共管理强调参与、信任、民主等思想相符合.要用协同论指导社会大卫生,卫生部门要在为人民服务的前提下与相应部门协调,做到"双赢".目前须用社会大卫生开发领导和医务人员,推动人人享有卫生保健和初级卫生保健;扎实做好城乡基层卫生工作,实行健康促进战略,提高全民健康素质,融社会大卫生于创建资源节约型和环境友好型社会之中.     

社会资本举办中医医疗机构在发展中存在的准入问题研究

为了更好地倡导和鼓励社会资本举办中医医疗机构,分析和探索社会办中医发展中的准入设置问题,对基层社会资本举办的中医医疗机构进行实地调查,并结合当下我国医疗机构准入设置政策法规,总结出社会资本举办中医机构的卫生规划、用地及主体性质、诊疗科目设置、人员配备以及资本进入等准入设置问题,政府在进行推进社会办中医政策研究中应重视此类准入设置问题.     

公立医院公益性体现与社会资本参与的关系研究

公立医院作为政府所属的事业单位,面对以药补医机制逐步破除,卫生服务补偿机制失衡的现实情况,一方面要研究公立医院公益性的体现与社会资本参与的可行性;另一方面要探索社会资本参与公立医院改革的可行方式,为公立医院改革提供政策和理论准备。     

社会大卫生——全球卫生工作发展的一个里程碑

社会大卫生是总结建国以来卫生工作成功经验的结晶,是全球卫生发展的又一里程碑。它把预防医学推向社会预防新水平,是我国对国际卫生的贡献。与WHO认为防治心脑血管病、癌症和儿童保健革命的“社会决定论”相符合,也与公共管理强调参与、信任、民主等思想相符合。要用协同论指导社会大卫生,卫生部门要在为人民服务的前提下与相应部门协调,做到“双赢”。目前须用社会大卫生开发领导和医务人员,推动人人享有卫生保健和初级卫生保健;扎实做好城乡基层卫生工作,实行健康促进战略,提高全民健康素质,融社会大卫生于创建资源节约型和环境友好型社会之中。     

医生角色的社会资本观

从宏观、中观和微观三个社会资本理论层面,分析了医生作为医疗服务市场中协调各利益相关集团关系的关键角色应该具备的职业特征和应该规范的职业行为,即通过正确发挥卫生政策执行者、救死扶伤的健康保护者、病人的朋友等职业角色来积累并利用社会资本,从而获得社会认可和自身可持续发展的动力。     

卫生保健领域中社会资本指标探讨

社会资本是促进人群健康和卫生行业发展的重要动力。结合我国医疗卫生国情剖析社会资本理论中信任、群众参与、社会网络、规范、互惠、能动性等指标的内涵,及其对人群健康、卫生机构乃至卫生保健全行业发展的影响,为开发和利用社会资本发展卫生事业、增进人群健康提供理论依据。     

医生角色的社会资本观

从宏观、中观和微观三个社会资本理论层面,分析了医生作为医疗服务市场中协调各利益相关集团关系的关键角色应该具备的职业特征和应该规范的职业行为,即通过正确发挥卫生政策执行者、救死扶伤的健康保护者、病人的朋友等职业角色来积累并利用社会资本,从而获得社会认可和自身可持续发展的动力.     

卫生保健领域中社会资本指标探讨

社会资本是促进人群健康和卫生行业发展的重要动力.结合我国医疗卫生国情剖析社会资本理论中信任、群众参与、社会网络、规范、互惠、能动性等指标的内涵,及其对人群健康、卫生机构乃至卫生保健全行业发展的影响,为开发和利用社会资本发展卫生事业、增进人群健康提供理论依据.     

Promoting social capital to alleviate loneliness and improve health among older people in Spain

Loneliness is especially frequent among older people in Southern Europe. Furthermore, promoting social capital to tackle loneliness and its health effects is an understudied intervention strategy. Therefore, a complex intervention was piloted in Spain in a pre–post study with a 2‐year follow‐up. Its aims were to explore the feasibility of the intervention and its short‐ and long‐term effects. It was conducted in one mixed rural–urban and two urban areas of diverse socioeconomic levels from 2011 to 2012. The intervention framework was based on social capital theory applying a behaviour change model and care co‐ordination. The intervention comprised: (i) a co‐ordinated action aimed at building a network between primary healthcare centres and community assets in the neighbourhood and (ii) a group‐based programme, which promoted social capital among lonely older people, especially social support and participation. Older people active in senior centres volunteered as gatekeepers. The main outcome domain was loneliness. Secondary outcome domains were participation, social support, self‐perceived health, quality of life, depressive symptoms and use of health resources. Pre–post changes were assessed with t‐test, Wilcoxon signed‐rank test and McNemar's test. Differences between the three time points were assessed with a one‐way ANOVA with repeated measures. Social workers and nurses were successfully involved as group leaders, 10 volunteers took part and 38 participants were included. After the intervention, loneliness decreased while social participation and support significantly increased. Furthermore, the number of visits to nurses increased. Exactly 65.8% of the participants built social contacts within the group and 47.4% became engaged in new activities. Two years later, social effects were maintained and depressive symptoms had decreased. Exactly 44.7% of the participants continued to be in contact with at least one person from the group and 39.5% continued participating. The intervention contributes a novel and feasible social capital‐based approach for alleviating loneliness among older adults while prompting meaningful changes in their lives.     

社会资本对社区卫生服务供需影响及对策研究

文章阐述了当前“社会资本”的两种具体涵义,较全面地分析了社会资本对社区卫生服务供需双方产生的影响,以期获得对社区卫生服务可持续发展更清晰的视角,并在此基础上提出相应措施.     

The desirability and feasibility of scaling up community health insurance in low-income settings--lessons from Armenia

There is growing evidence that community financing mechanisms can raise additional revenue, increase equitable access to primary health care (PHC), and improve social protection. More recently there has been interest in scaling up community financing as a step towards universal coverage either via tax-based systems or social health insurance. Using key informant interviews and focus group discussions, this study sought to assess the desirability and feasibility of scaling-up community health insurance in Armenia. The results suggest that there is broad-based political support for scaling up the schemes and that community financing is synergistic with major health sector reforms. High levels of social capital within the rural communities should facilitate scaling up. Existing schemes have increased access and quality of care, but expansion of coverage is constrained by affordability, poor infrastructure, and weak linkages with the broader health system. Long-term subsidies and system-building will be essential if the expanded schemes are to be financially viable and pro-poor. Overall, successfully scaling up community financing in Armenia would depend on addressing a range of obstacles related to legislation, institutional capacity, human resources and resistance to change among certain stakeholders.     

The importance of gender and conceptualization for understanding the association between collective social capital and health: a multilevel analysis from northern Sweden

Growing research on social capital and health has fuelled the debate on whether there is a place effect on health. A central question is whether health inequality between places is due to differences in the composition of people living in these places (compositional effect) or differences in the local social and physical environments (contextual effects). Despite extensive use of multilevel approaches that allows controlling for whether the effects of collective social capital are confounded by access to social capital at the individual level, the picture remains unclear. Recent studies indicate that contextual effects on health may vary for different population subgroups and measuring "average" contextual effects on health for a whole population might therefore be inappropriate. In this study from northern Sweden, we investigated the associations between collective social capital and self-rated health for men and women separately, to understand if health effects of collective social capital are gendered. Two measures of collective social capital were used: one conventional measure (aggregated measures of trust, participation and voting) and one specific place-related (neighbourhood) measure. The results show a positive association between collective social capital and self-rated health for women but not for men. Regardless of the measure used, women who live in very high social capital neighbourhoods are more likely to rate their health as good-fair, compared to women who live in very low social capital neighbourhoods. The health effects of collective social capital might thus be gendered in favour for women. However, a more equal involvement of men and women in the domestic sphere would potentially benefit men in this matter. When controlling for socioeconomic, sociodemographic and social capital attributes at the individual level, the relationship between women's health and collective social capital remained statistically significant when using the neighbourhood-related measure but not when using the conventional measure. Our results support the view that a neighbourhood-related measure provides a clearer picture of the health effects of collective social capital, at least for women.     

The practitioners’ perspective on the upside and downside of applying social capital concept in therapeutic settings

Social capital, and more particularly the social networks that define its existence, is said to benefit health and well‐being. In individuals recovering from alcohol and drug addiction, social capital accruing from social networks support treatment, recovery and maintenance. Therefore, the concept of social capital is important for public health practitioners working in recovery interventions. This qualitative study seeks to explore what practitioners perceive as the importance of social capital and how they apply the concept in interventions to support individuals recovering from drug and alcohol addiction. Eight public health practitioners involved in drug and substance abuse interventions in West Yorkshire, England, were interviewed. The results of the interview were then deductively coded using two priori themes of perceived impact of social capital on health outcomes and application of social capital theory in recovery interventions. The findings reveal that practitioners understand the impact of social capital as the effects of social networks on recovery and apply the concept in their interventions. However, the nature of interventions created based on similarities in condition (alcohol and substance addiction) and intended outcome (recovery) create bonding social capital with mixed outcomes. This paper argues that the wider benefits to service users are unintentionally inhibited by the overwhelming downsides of bonding social capital. For instance, closed support groups comprised of individuals with high similarities further exclude the already socioeconomically deprived service users from integrating and accessing resources outside their groups.     

Chat room computer-mediated support on health issues for aboriginal women

Within contemporary health care, increases in chronic disease have necessitated a disease management focus. Given that chronic disease is managed, more so than cured, there are increased demands for greater participation by health care consumers and they are expectated to take on increased responsibility for self-care. The emphasis on consumer responsibility has increased the significance of health-promoting behavior change in contending with contemporary health care concerns. In Canada, the reported inequity in health status between Aboriginal and non-Aboriginal Canadians further emphasizes the need for innovative health strategies. For Aboriginal women isolated by geography, changing societal norms (e.g., women working outside of the home, single parent families), and cultural distinction, online chat participation serves as a novel medium for the provision of health knowledge, support, and motivation within a virtual "neighborhood." Recognizing the significance of social support in the promotion of positive health behavior change, we investigated the theme of social support within health conversations among Aboriginal women participating in an online chat room. Content analysis was the primary methodological focus within a mixed methods approach. Of 101 health-based online conversations, the majority reflected one of three forms of social support: (1) emotional support, (2) informational support, or (3) instrumental support. The value of social support and social cohesion within health has been well documented. The current investigation suggests that "community" need not be physically constructed; virtual communities offer great potential for social cohesion around the issues of health and health care.     

The dynamics of socio-connective trust within support networks accessed by informal caregivers

This article introduces the concept of socio-connective trust, the synapse between the social structures and processes that underpin relationships in supportive care networks. Data from an ethnographic case study of 18 informal caregivers providing in-home care for people with life-limiting illness were analysed drawing on theoretical concepts from the work of Giddens and writings on social capital, as well as the construction of trust in the caregiving literature. While conceptions of trust were found to contribute to understanding supportive care relationships, they did not account for the dynamic nature of the availability and use of support networks. Instead, informal caregivers undertook ongoing reflexive negotiation of relationship boundaries in response to their own conception of the current situation and their perception of trust in their relationships with the various members of the support network. The concept of socio-connective trust describes the movement and flow of the flexible bonds that influence relationships among care networks and determine the type and range of support accessed by informal caregivers. Understanding the complexities of socio-connective trust in caregiving relationships will assist health and social care workers to mobilize relevant resources to support informal caregivers.     

Social capital,collective efficacy and the provision of social support services and amenities by municipalities in the Netherlands

Differential provision of local services and amenities has been proposed as a mechanism behind the relationship between social capital and health. The aim of this study was to investigate whether social capital and collective efficacy are related to the provision of social support services and amenities in Dutch municipalities, against a background of decentralisation of long‐term care to municipalities. We used data on neighbourhood social capital, collective efficacy (the extent to which people are willing to work for the common good), and the provision of services and amenities in 2012. We included the services municipalities provide to support informal caregivers (e.g. respite care), individual services and support (e.g. domiciliary help), and general and collective services and amenities (e.g. lending point for wheelchairs). Data for social capital were collected between May 2011 and September 2012. Social capital was measured by focusing on contacts between neighbours. A social capital measure was estimated for 414 municipalities with ecometric measurements. A measure of collective efficacy was constructed based on information about the experienced responsibility for the liveability of the neighbourhood by residents in 2012, average charity collection returns in municipalities in 2012, voter turnout at the municipal elections in 2010 and the percentage of blood donors in 2012. We conducted Poisson regression and negative binomial regression to test our hypotheses. We found no relationship between social capital and the provision of services and amenities in municipalities. We found an interaction effect (coefficient = 3.11, 95% CI = 0.72–5.51, P = 0.011) of social capital and collective efficacy on the provision of support services for informal caregivers in rural municipalities. To gain more insight in the relationship between social capital and health, it will be important to study the relationship between social capital and differential provision of services and amenities more extensively and in different contexts.     

Lost in translation: a genealogy of the "social capital" concept in public health

STUDY OBJECTIVE: To examine the genealogy of the social capital concept in public health, with attention to the epistemological concerns and academic practices that shaped the way in which this concept was translated into public health. DESIGN: A citation-network path analysis of the public health literature on social capital was used to generate a genealogy of the social capital concept in public health. The analysis identifies the intellectual sources, influential texts, and developments in the conceptualisation of social capital in public health. PARTICIPANTS: The population of 227 texts (articles, books, reports) was selected in two phases. Phase 1 texts were articles in the PubMed database with "social capital" in their title published before 2003 (n = 65). Phase 2 texts are those texts cited more than once by phase 1 articles (n = 165). MAIN RESULTS: The analysis shows how the scholarship of Robert Putnam has been absorbed into public health research, how three seminal texts appearing in 1996 and 1997 helped shape the communitarian form that the social capital concept has assumed in public health, and how both were influenced by the epistemological context of social epidemiology at the time. CONCLUSIONS: Originally viewed in public health research as an ecological level, psychosocial mechanism that might mediate the income inequality-health pathway, the dominance of the communitarian approach to social capital has given disproportionate attention to normative and associational properties of places. Network approaches to social capital were lost in this translation. Recovering them is key to a full translation and conceptualisation of social capital in public health.     

社会资本在健康领域的应用现状

在解释收入不平等对健康差异的影响作用时，流行病学家引入了社会资本的概念，尽管社会资本理论自身还存在很多争议，但其与健康关系的研究引起了众多学者的兴趣。本文从各种社会资本的概念，社会资本在健康领域研究中的应用，社会资本影响健康的可能机制，各种测量方法和存在的不足以及在中国目前的应用现状等方面进行了浅析。