機構式長期照護服務使用之相關因素探討：社區環境與個人背景因素的分析

曾淑芬(Su-Fen Tzeng)

指導教授 ： 吳淑瓊

國立臺灣大學/公共衛生學院/衛生政策與管理研究所/博士(2005年)

https://doi.org/10.6342/NTU.2005.10410

摘要

老人因慢性失能導致長期照護需求日漸高漲，其中機構式照護服務使用的議題，更隨著社會對老人照護成本及照護品質的關注而為長期照護領域重要的研究課題，而過去研究探討老人機構是照護服務使用的影響因素主要是從個人及家庭等層面切入，較缺乏從社區層面來加以探討與了解，老人使用機構的因素多元且廣泛，若能從宏觀角度以生態模式的系統思維來進一步釐清影響老人使用機構式照護的個人與社區不同層次相關因素，對我國長期照護政策的規劃應有重要的參考價值。
本研究目的主要有四：一、了解老人機構式照護服務使用的人口及地區分佈狀況；二、探討影響老人使用機構式照護服務的個人因素；三、探討影響老人使用機構式照護服務之社區環境因素；四、分析社區與個人因素間的相互作用效果，以了解其對老人使用機構式照護服務的影響性。
本研究係採用橫斷研究法，以「全國長期照護需要評估」第二階段調查中，65歲以上之失能老人為研究樣本，進行描述性分析、雙變項分析、邏輯斯迴歸分析及層級迴歸模式分析。本研究樣本共計12,979人，其中有11,777人來自社區，1,202人來自長期照護機構。
研究結果顯示老人在過去一年曾使用機構式照護服務的比例為11.8﹪。而在老人機構使用的個人特質分布中，有使用機構的老人以85歲以上、男性、教育程度在高中以上、無子女、無偶、外省老人、低收入戶、重度依賴及完全依賴老人、認知功能重度障礙老人、有護理需要者、有問題行為的老人、及罹慢性病較多的老人有使用機構的比例最高。至於地區分布方面，在女性勞動參與率及工商產業密度較高的現代化社區中，老人有使用機構的比例在12﹪以上；而在機構式照護服務資源較多的社區中，老人使用機構的比率（15.1﹪）也比資源較少的地區（8.9﹪）來得高。
以邏輯斯迴歸分析影響老人機構式照護服務使用的個人因素，結果顯示前傾因素中的年齡、性別、教育程度、籍貫、子女數及婚姻狀況等因素具有顯著影響，當控制社區層級的隨機變異效果之後，上述個人因素的影響仍持續存在。在需要因素方面，機構式照護服務的使用與老人的依賴程度、認知功能障礙程度、及技術性護理需要等因素有顯著相關，且在考量社區因素後，其顯著影響性仍持續存在。至於在使能因素方面，在同時考量個人背景與社區因素之後，低收入戶及具雙重福利身分的老人機構使用的機率均明顯高於一般戶老人，其機構使用的勝算比分別為2.94及3.29。
而社區因素的層級迴歸模式分析結果顯示，社區中女性勞動參與及工商產業密度等兩項社區現代化特性與老人的機構使用有顯著的相關，在控制個人背景及社區資源因素之後，高度現代化特性社區老人機構使用的勝算比為1.08。此外社區中的機構式照護資源配置對老人機構使用的影響成正比，相對於參考組（低度資源區），高度資源區老人機構使用勝算比為1.37；而在醫療照護資源較多的社區老人機構使用也比低度資源區多，在高度醫寮資源區老人機構使用勝算比為1.12。至於社區式照護資源與老人機構使用的關係則不顯著。
社區因素會透過個人背景不同的作用而對機構使用產生間接效果。結果顯示社區因素會作用於年齡、性別、籍貫、子女狀況、婚姻狀況、依賴程度、認知功能障礙程度、及技術性護理需要等個人因素，而對老人機構使用斜率產生正向的擴大效果。至於社區因素與個人依賴程度間的交互作用方面；社區現代化特性與依賴程度間的相互作用對老人機構使用的影響有顯著性，而社區資源方面，依賴程度與機構式照護資源、及醫療照護資源間的交互作用影響有顯著性，但與社區式照護資源間的交互作用對老人機構使用影響則不顯著。
從本研究結果顯示社區與個人因素都會對老人機構使用有所影響，因此建議在長期照護相關政策規劃上，應依社區特性不同，而有個別性考量，並積極檢討現有長期照護資源的配置狀況，以符合地區民眾對長期照護需要的期望；此外，為顧及老人在機構式照護服務使用的異質性，政策上應依老人不同特性組合，評估所需的長期照護服務，以作為預測未來長期照護需要的基礎。

關鍵字

社區環境因素 ； 照護服務使用 ； 機構式長期照護

並列摘要

The needs of long-term care have been increasing because of elderly people experiencing chronic disability. With the costs and quality of elderly care drawing greater attention, institutional care utilization has become an important issue in long-term care. Previous literature on institutional care utilization was mainly based on individual and familial perspectives, with a lack of incorporating community factors into consideration. Given the complexity of factors in relation to institutional care utilization, an ecological approach to investigating both individual and ommunity effects on utilization will provide valuable implications for long-term care policy in Taiwan.

This study aimed to: 1). understand the utilization of institutional care by elderly people in Taiwan, and its distribution by geographic areas; 2). identify individual-level factors of institutional care utilization; 3).examine community-level determinants of institutional care utilization; and 4). Investigate the effects of interaction between individual and community-level factors on institutional care utilization.

This research pertained to a cross-sectional design, using data collected in the second-stage survey of “ 2001 Long-term Care Need Assessment in Taiwan” A national representative sample of 12,979 disabled individuals aged 65 were studied, with 11,777 from the community and 1,202 from long-term care institutions. The study performed descriptive, bivariate, logistic regression, and multilevel analyses.

The result showed that 11.8% of elderly people had received institutional care in the past year. With respect to the individual-level factors, higher percentages of institutional care utilization were found in those who were 85 years old and over, male, at least with high school diploma, mainlanders, entitled to low-income supplements, with no spouse, with no children, and those who were severely or completely dependent, with profound cognitive impairment, with problem behaviors, in need of nursing care, and had more chronic conditions. In terms of community-level characteristics, utilization was 12% in areas with higher rates of female employment and levels of industrialization.

Logistic regression analyses showed that, predisposing factors including age, education, ethnicity, number of children, and marital status were significantly associated with institutional care utilization. After controlling for community-level, the aforementioned effects of individual factors persisted. As far as demand factors were concerned, the level of dependency, cognitive impairment and needs in nursing care were significantly related to utilization. Such associations remained significant after community characteristics were controlled. In terms of enabling factors, the probability of using institutional care was 2.94 times higher for low-income elderly and 3.29 times higher for those entitled to multiple welfare programs, with both individual and community variables controlled.

Hierarchical linear regression analyses revealed that female employment and industrialization were significant community-level predictors of institutional care utilization. After controlling for individual characteristics and variables related to community resources, the probability of care utilization was 1.08 greater in highly industrialized areas. Besides, a statistically positive association was found between resources availability and utilization. The odds ratio was 1.37 in high-resource areas compared to low resource areas. Similar pattern was observed with respect to medical care resources, with an odds ratio of 1.12. No statistically significant relationship was found between the availability of community-based services and utilization.

Community impacts on institutional care utilization were mediated by individual factors. The results showed that community exerted it effects on individual attributes including age, sex, ethnicity, availability of children, marital status, levels of dependency and cognitive impairment, and nursing care needs, and reinforced the propensity of institutional care utilization. With respect to the interaction effects of dependency with community factors, only institutional and medical care resources were found to have interaction effects on utilization but not community-based services.

This study concluded that institutional care utilization was determined both by community and individual-level factors. The findings provided important implications for long-term care policy, particularly directed to the distribution of resources in consideration of community features, and the demand for long term care from the community perspective. In addition, the differential utilization of institutional care suggested that policy planning be concerned about subgroups of elderly people with different individual characteristics through need assessment. It is also crucial for the prediction of future needs in long-term care.

並列關鍵字

Long Term Care utilization ； Service utilization ； Community indicator

參考文獻

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