慢性病病人之成人健康知能程度與醫療資源利用相關性之研究

目的健康知能(health literacy)是指在健康照護體系之下，能閱讀，理解以及書寫文件的能力。而功能性健康知能(functional health literacy)又特指能運用閱讀與數字技巧於健康照護體系環境的能力。國外研究顯示，健康知能可能是影響慢性病病患健康知識、健康行為、遵從醫囑行為、用藥常識以及慢性病自我照護行為的重要因子。本研究採用1999年Baker與Parker等所共同發表的成人功能性健康知能測驗簡短版(Short Test of Functional Health Literacy in Adults, S-TOFHLA)進行中文翻譯與修訂，以成本研究用之問卷，用以測驗本國民眾健康知能程度，以瞭解慢性病病人之健康知能程度與其醫療資源利用的關係。本研究的目的包括一、引進成人功能性健康知能測驗，並配合國內社會、文化情形，進行適度中文版的修訂。二、瞭解慢性病病人的成人健康知能程度的高、低與分布。三、探討健康知能程度與慢性病病人之性別、年齡、族群、社經程度等人口學特徵變項之差異。四、探討慢性病病人之成人健康知能程度與醫療資源利用之關係。方法本研究之設計係採取回溯性、橫斷式研究設計模式，以結構式問卷收集之初級資料(primary data)，建立慢性病病人之健康知能程度及基本人口學特徵資料庫；醫療資源利用則採用衛生署旗山醫院醫療費用資料庫之次級資料(secondary data)進行分析。問卷內容包括基本資料與健康知能測驗二部分。健康知能測驗係翻譯自成人功能性健康知能測驗簡短版(S-TOFHLA)；基本資料則包括，性別、年齡、族群、家庭年收入及受教育年限。本研究資料收集方式採方便取樣方式進行，以主診斷為糖尿病、心臟疾病、高血壓、攝護腺肥大等慢性病病人，同意接受研究並簽署研究同意書者，作為研究對象，於2007年10月至2008年3月間共收集355位至衛生署旗山醫院就診且符合收案條件之慢性病病人，再回溯受訪者於2005年1月1日至2008年1月1日共三年期間，在署立旗山醫院之所有醫療資源利用情形，包括有門診就診次數、急診就診次數，住院日數及醫療費用做分析比對。結果總共有355位慢性病病人符合條件進入本研究，其中男性221位(62%)，女性134位(38%)；平均年齡67±11.0歲，大於65歲以上者有214位(60%)；平均受教育年限7.6±4.4年，≦8年有208位(59%)；家庭年收入20萬元以下有216位(61%)；閩南族群213位(60%)，客家族群112位(31%)，外省族群30位(9%)。健康知能測驗總分平均為59.4±29.6分，數字理解與運用知能測驗總分平均為18.8±9.6分，文字理解與運用知能測驗總分平均為40.6±23.1分，健康知能適當組(67~100分)有184位(52%)，健康知能不適邊緣組(54~66分)有37位(10%)，健康知能不適當組(0~53分)有134位(38%)。男性與女性健康知能測驗總分平均各為62.8±25.0分與53.8±35.2分，兩組有顯著差異(p＝0.010)。以單因子變異數分析不同年齡層其健康知能測驗總分有顯著差異(p<0.001)；不同受教育程度其健康知能測驗總分有顯著差異(p<0.001)；不同家庭年收入其健康知能測驗總分有顯著差異(p<0.001)；不同族群其健康知能測驗總分沒有顯著差異(p=0.135)。健康知能測驗總分與年齡有顯著負相關；健康知能測驗總分與受教育年限有顯著正相關。健康知能測驗總分與門診次數及門診醫療費用無顯著相關；健康知能測驗總分與急診次數、住院日數、急診醫療費用、住院醫療費用與總醫療費用均有顯著負相關。結論與建議本研究結果發現年齡愈高健康知能測驗總分愈低；社經程度愈高，包括受教育年限愈長，家庭年收入愈高，其健康知能程度明顯較高。健康知能程度與門診之看診次數與門診醫療費用沒有顯著相關性，但健康知能測驗程度愈差急診看診次數較多，急診醫療費用較高，住院日數較長，住院醫療費用及總醫療費用均較高。結果顯示健康知能不適當的慢性病病人，醫療資源利用顯著增加，特別是急診與住院的醫療資源利用增加。健康知能可能是影響慢性病病人醫療資源利用的重要因子。因此建議應提升慢性病病人健康知能，積極改善慢性病病人衛生教育、增加健康知識、促進健康行為以及加強慢性病自我照護行為，將可以避免醫療資源之浪費。

關鍵字

成人健康知能；慢性病；醫療利用

並列摘要

OBJECTIVES Health literacy is the ability to read and understand written materials commonly encountered in health care settings. However, functional health literacy indicates the reading and numeracy skills required to fully understand and act on health information. According to the previous studies, health literacy could play an important role in affecting health knowledge, health behavior, refill adherence, understanding prescription list and self-management skills of chronic disease patients. We translate and edit the Short Test of Functional Health Literacy in adults (S-TOFHLA) developed by Baker et.al. in 1999 to Chinese edition. In this study, we use the translated S-TOFHLA Chinese test to examine health literacy level for Taiwanese. Our aim is to research the relationship between health literacy level and medical resource utilization in chronic disease adults. The objectives in our study are: 1.Introduce the popular short test of functional health literacy in adults into Taiwan in Chinese edition. We try to revise the examination to adapt to our culture and society. 2. Survey the percentage and distribution of health literacy adequate, marginal and inadequate levels in chronic disease adults. 3. Discuss the differences of the demographic characters such as gender, age, socioeconomic status, and ethnicity with health literacy level in chronic disease adults. 4. Analyze the relationship between the health literacy level and medical resource utilization in chronic disease adults. METHODS This was a retrospective, cross-sectional design study. We used structural questionnaires to collect the information about demography and health literacy of chronic disease patients. Medical resource utilization data was a secondary data from Chi-Shan hospital medical utilization database. Health literacy was examined by the S-TOFHLA and demographic characteristics including gender, age, ethnicity, and socioeconomic status. Study population was sampling with convenience method in Chi-Shan hospital OPD. From 2007 October to 2008 March, there were 355 patients with diagnosis of diabetes, hypertension, heart disease, and benign prostate enlargement enrolled into this study. All the participants needed to sign the informed consent of the survey. Medical resource utilization was defined as the frequency of OPD visit, the frequency of ER visit, the days of admission and the costs of medical resource from 2005-1-1 to 2008-1-1 of the participants. RESULTS All 355 patients were eligible and enrolled into this study. There were 221 (62%) male and the other 134(38%) female participants. Mean age at enrollment was 67±11 years, while 214(60%) participants were older than 65 years. Mean education years of patients were 7.6±4.4 years, while 208(59%) cases average education year less than 8 years. All of 216(61%) cases had total annual income of family less than 200 thousand NTD. All cases of 213(60%) were Minnan ethnic population, 112(31%) were Hakka population, and 30(9%) were Mainlander population. Average functional health literacy scores were 59.4±29.6；average numeracy scores were 18.8±9.6；average reading comprehension scores were 40.6±23.1, respectively. There were 184(52%) cases in adequate literacy group (67~100 scores)，37(10%) cases in marginal literacy group (54~66 scores), and the other 134(38%) cases in inadequate literacy group (0~53 scores). Mean scores of health literacy of male were statistic difference than female (62.8±25.0 versus 53.8±35.2, p=0.010). There were significant differences in functional health literacy across age groups, education strata, and annul family income strata (p<0.001) in ANOVA. Across ethnicity groups, no significant differences was found in functional health literacy (p=0.135). Sum of health literacy scores was significantly associated with age and education years. However, sum of health literacy scores was not significantly associated with frequency of OPD visit and costs of OPD visit. In addition, sum of health literacy scores was significant negative association with frequency of ER visits, days of admission, costs of ER, costs of admission, and all medical costs. CONCLUSION AND SUGGESTION In this study, the elder patients had less health literacy scores than the younger; while, the more education years, annual family income, the more sum of health literacy scores. Health literacy was not associated with frequency and costs of OPD visit. However, health illiteracy was significant increasing the frequency of ER visit, longer hospital stay, more expensive costs of ER, admission and total medical utilization. Our results implied that health illiteracy would induce medical utilization, especially in ER and hospital stay costs. Health literacy could be an important medical utilization factor in chronic disease patients. We suggested that health education augmentation, health knowledge promotion, healthy behavior enhancement, and self-management reinforcement would be the strategies to improve functional health literacy in chronic disease patients. Improving health literacy of chronic disease adults might mitigate the expenditure of medical utilization and reduce the unnecessary medical waste.