以健康信念模式探討社區老人預防衰弱行為之相關因子

台灣在2018年成為高齡社會，持續增加的老年人口，將對社會及健康照護體系帶來極大的威脅。衰弱是伴隨老化生理系統儲備能力減損、健康風險增加的狀態，會造成跌倒、失能及死亡等不良預後，而慢性疾病與老化造成的加乘效應，更增加衰弱的風險，其衍生而來的照護問題也將耗費龐大的社會和醫療成本。不過，健康的生活方式和預防特定衰弱風險因子可以預防和延緩衰弱，本研究以健康信念模式為基礎架構，探討社區長者健康信念、預防衰弱健康行為與衰弱之關係及重要預測因子。研究方法採橫斷式研究，對240位居住於臺北市大安區65歲以上社區長者進行Kihon Checklist (KCL)衰弱篩檢與健康信念問卷調查。研究結果顯示社區之衰弱長者以高齡、多重慢病者居多，半數以上的研究對象不知道衰弱症及預防方法，同時也缺乏衰弱相關知識的來源管道。健康信念與衰弱的關係中發現，衰弱組受到衰弱症的威脅感高於衰弱前期組與無衰弱長者，且認同完整的健康狀態可以擁有較高生活品質，有較高健康信念(p< .001)；自我效能(p< .001)和預防衰弱行為(p< .001)則顯示衰弱組的長者受到身心退化、疾病及生活障礙等影響，對預防衰弱之健康促進行為的信心和執行力皆較其他兩組差。多變量線性迴歸分析運用廣義相加模型（含交互作用）進行衰弱因子之預測，結果顯示年齡越長則衰弱程度越高且有劑量效應的關係，90歲(含)以上(p< .0001)、85-89歲(p= .0097)、80-84歲(p= .0036)、75-79歲(p= .0061)為顯著；非獨居有中風(p= .0004)、非獨居有視力問題(p= .0045)、關節炎(p= .0002)、骨折或關節損傷(p= .0017)、經濟非充裕(p= .0409)、知識總分≤ 3.8分(p= .0484)的長者皆為衰弱的風險因子。在健康信念的部分，自覺罹患性(p< .0001)和自覺行動利益(p= .0247)分數越高則越衰弱，自我效能(p< .0001)分數越高則越不衰弱為保護因子，自覺嚴重性分數≤5.9分或>12.8分(p= .0008)比較衰弱，獨居且採取預防衰弱行動線索(p< .0001)的長者也偏向衰弱。結果可被全體自變項共同解釋62.8%。研究對象衰弱篩檢(KCL)之異常構面依序為運動功能(37.1%)、口腔功能(25.4%)、憂鬱傾向(16.9%)、認知(16.2%)、生活(13.3%)、社會功能(12.8%)及營養(9.3%)。Kruskal-Wallis rank-sum test結果顯示衰弱症之特定風險為運動功能異常、口腔功能異常和憂鬱傾向，受到年齡和累積疾病數的影響最劇，而經濟的匱乏則可能加重衰弱情形。建議社區衰弱防治策略，首先在「可近性」的部分增加衰弱知識和預防方法的來源管道，如結合醫療院所和門診，對有就醫習慣的長者定期篩檢與衛教，降低長者行動線索的障礙。次為「教育面」，依照長者衰弱程度設計不同強度、複合式主題的健康促進內容或強化訓練，加深長者對衰弱症的健康信念，運用自我效能為衰弱症的保護因子，著重在使能(enabling)、復能(reablement)和建構支持性環境，協助長者發展特定生活功能之熟練經驗，增進或維持長者活動機能與適應能力。第三部分為「照顧面」，以老人為中心預防和延緩失能，從健康服務中心、衛生所到醫療院所實行衰弱防治三段五級的照護模式，落實持續和完整的照護網絡；對衰弱長者提供個案管理、復能訓練、建構支持性環境、專業醫療照護、長期照顧服務等；對衰弱前期、高風險長者邀約健康訓練或促進課程，使長者在有限的內在能力(intrinsic capacity, IC)下，將功能能力(functional ability, FA)最大化，盡可能地減低失能或降低對社會的依賴，達到最佳與獨立的功能狀態，成功邁向健康老化。

關鍵字

衰弱症；社區老人；健康信念模式；預防衰弱行為

並列摘要

Taiwan has become an aged society since 2018. Frailty is an age-related syndrome characterized by declining functioning across multiple physiological systems. Effective methods to prevent or delay the onset of frailty are urgently needed in aging societies. Lifestyle and clinical risk factors are potentially modifiable by specific interventions and preventive actions. The purpose of this study was to investigate frailty status and associated factors in health beliefs and frailty prevention behavior among community-dwelling elderly. This research was a cross-sectional study. A total of 240 aged 65 and over were recruited from home visits and health promotion courses by community nurses in Taipei city. Categorized by Kihon Checklist (KCL) index, scores of 0-3 classified as robust (n=120), 4-7 as pre-frail (n=60), and 8+ as frail (n=60). Structured questionnaires based on the Health Belief Model (HBM) were used to collect data. The research participants were 65% women aged 65 to 98 years. The frail elderly were mainly of advanced age and had multiple chronic diseases. More than half are unaware of frailty, prevention methods, and action cues. According to the Kruskal-Wallis rank-sum test, frailty was positively correlated with health beliefs (p< .001). Seniors with higher KCL scores were more aware of frailty risks and agreed that being in good health is associated with a higher quality of life. Furthermore, self-efficacy (p< .001) and frailty prevention behavior (p< .001) were negatively correlated with frailty, indicating that the frailty elderly would be more protected if they had higher self-confidence and execution ability in implementing healthy behaviors. Multiple linear regressions with generalized additive models (GAMs) and interaction variables were used to predict the total scores of KCL. The results indicated that frailty increased with age, and a dose-effect relationship was observed. Over 90 years old (p< .0001), 85-89 (p= .0097), 80-84 (p= .0036), and 75-79 (p= .0061) were significantly different. The older persons who did not live alone with stroke (p= .0004), did not live alone with vision impairment (p= .0045), suffering from arthritis (p= .0002), suffering from bone and joint injuries (p= .0017), and having economic insufficiency (p= .0409), knowledge scores ≤ 3.8 (p= .0484) were all risk factors for frailty. A higher perceived susceptibility score (p< .0001), perceived benefit of action (p = .0247), and perceived severity score of ≤5.9 or >12.8 (p = .0008) were associated with frailty in the health belief model. An increase in self-efficacy (p< .0001) was associated with a decrease in frailty. Elderly individuals who lived alone and took action to prevent frailty (p< .001) were also frailer. In the abnormal aspects of KCL domain, the frailty group had the worst detection results. Of all subjects followed by were poor motor function (37.1%), oral dysfunction (25.4%), depression tendency (16.9%), mild cognition impairment (16.2%), life dysfunction (13.3%), social dysfunction (12.8%), and nutrition problems (9.3%). Kruskal-Wallis rank-sum test showed three specific risks of frailty, poor movement, oral dysfunction, and depression tendency, strongly influenced by age and the cumulative number of illnesses. At the same time, lack of financial could exacerbate frailness. Recommendations for frailty prevention strategies were three. First, add sources of frailty prevention clues, such as regular screening and health education for the elderly in the outpatient clinic, to the "accessibility knowledge" section. The second section is "education." Design various intensities and comprehensive broad classes to raise awareness of the perceived susceptibility and benefits of prevention frailty, and arrange successful models to enhance their self-efficacy in promoting healthy behavior and lifestyle. The final section is "caring." Implements a three-stage and five-level prevention strategy to prevent and delay frailty. Case management provides rehabilitation training, a supportive environment, medical and long-term care, and other services to help older people maximize their functional ability and achieve independence.