| Background and objectives:Aging is a major social problem in the 21st century.At present,China is the country with the largest population in the world.With the deterioration of the physique of the elderly and the acceleration of aging,the health problems of the elderly are becoming more and more serious.Health-related quality of life of the elderly is also the focus of many scholars.Progress in aging of population not only influences on development of social economy,but also poses significant challenges to health care in China.Health management is a promising way to change the defects of existing health service mode,reduce medical expenses and cope with the aging of population,but its specific implementation and effectiveness need to be further confirmed.This study investigated Health-related Quality of Life?HRQoL?of the community-dwelling elderly and the prevalence of chronic diseases to understand the health status of the elderly and its factors.The intervention trial on health management was carried out for the community-dwelling elderly,and the model about the effective evaluation of health management based on HRQoL was constructed to provide evidence for the effective community health management program for the elderly.Methods:?1?A cluster random sampling method was used to select the community-dwelling elderly in a district of Nanjing as the subjects,a cross-sectional study was carried out from March to December in 2013.The questionnaire survey method was used to measure HRQoL of the community-dwelling elderly and information on chronic diseases was collected by the ways of self-reporting and physical examination.By using SAS 9.3 and SPSS 19.0 softwares,the statistical methods which included descriptive statistics,Logistic regression model,factor analysis and multiple linear regression model were used to study HRQoL and its factors and the prevalence of chronic diseases among the community-dwelling elderly.?2?A 30-month longitudinal study was carried out among the elderly with hypertension or diabetes and those without chronic diseases in the above-mentioned cross-sectional study to follow up the activities of daily living?ADL?and self-rated health?SRH?.Besides,the causes of loss to follow-up?death,non death?were recorded.Bayesian joint model was fitted to analyze the long-term health status of the elderly and its factors,and to study the predictive value of ADL and SRH to death.These analyses were conducted by using R 3.4.1 and OpenBUGS 3.2.3softwares.?3?According to the health management program put forward by our research group,a 24-month intervention trial on health management?from January 2014 to December 2015?was carried out among the community-dwelling elderly with repeated measurement of their HRQoL.Complete data was enrolled and Bayesian beta mixed model was built to evaluate the effectiveness of health management.R 3.4.1 and OpenBUGS 3.2.3 softwares were used to conduct the analyses.Results:?1?A total of 2681 community-dwelling elderly persons were investigated in the cross-sectional study and 2452 persons were enrolled in the analysis.Information on thirteen chronic diseases were collected,the prevalence of chronic diseases was 74.6%,the highest prevalence was hypertension?48.0%?,followed by diabetes?21.9%?.The prevalence of multimorbidity??2 chronic diseases?was 49.4%.The observed prevalence of six chronic disease pairs was higher than their expected prevalence,including hypertension and diabetes,hypertension and coronary heart disease,hypertension and dyslipidaemia,diabetes and cataract,diabetes and hearing disorder,hypertension and stroke.Three patterns were detected by factor analysis as follows:the first pattern covered degenerative diseases?hearing disorder,cataract,joint disease?and cancer;The second pattern was characterized by liver disease,lung disease,gastrointestinal disease;And the third pattern was characterized by cardiovascular diseases?dyslipidaemia,hypertension,coronary heart disease?,metabolic diseases?diabetes?and kidney disease.Descriptive statistics for the elderly with the index score of HRQoL?3 indicated the proportion of the indicators?3 on the dimensions of physical function,emotional personality,memory function and social adaptation was more than 20%,and the indicators did not include long-term memory,family harmony,and the level of relying on family.On the dimensions of ADL,the proportion of the indicators except their own cooking?3 was less than 5%.Multivariate analyses on the factors of HRQoL showed age and multiomorbidity were negatively associated with the scores of all dimensions and general health?P?0.05?;One chronic disease was negatively associated with the scores of physical function,memory function,social adaptation and general health?P?0.05?;The educational level of senior high school was positively associated with the scores of ADL,emotional personality,social adaptation and general health?P<0.05?;No spouse?single,divorced,widowed?was negatively associated with the scores of ADL,emotional personality,social adaptation and general health?P?0.05?;Solitude had a significant impact on the score of ADL?P?0.05?,living with children had a significant impact on the scores of physical function,memory function and social adaptation?P?0.05?;Sufficient physical exercise was positively associated with the scores of physical function,emotional personality,social adaptation and general health?P?0.05?;Smoking experience was negatively associated with the scores of physical function and general health?P?0.05?.?2?At the baseline,the elderly with hypertension?n=1177?,diabetes?n=537?,and without chronic diseases?n=622?were enrolled in the longitudinal study.The number of follow-up at the end was 1002,447 and 541,respectively.According to the results of Bayesian joint model,among the elderly with hypertension,the protective factors of ADL included higher education level???95%CI?=-0.49?-0.91,-0.11??,sufficient physical exercise???95%CI?=-0.98?-1.35,-0.61??,and risk factors included suffering from other chronic diseases???95%CI?=0.25?0.07,0.47??,time???95%CI?=0.72?0.61,0.83??.The risk factors that affected the probability of remaining in or transitioning to the unhealthy state included age???95%CI?=1.13?0.99,1.28??,suffering from other chronic diseases???95%CI?=2.48?1.83,3.89??,time???95%CI?=5.68?2.26,9.04??,and the protective factor was higher education level???95%CI?=-1.27?-1.46,-1.09??,sufficient physical exercise???95%CI?=-1.34?-1.53,-1.15??.Loss to follow-up caused by death was associated with lower SRH and ADL(??95%CI??ADL?=1.65?1.07,2.29?,??95%CI??SRH?=2.35?1.22,3.57?).The higher risk of death was associated with higher age???95%CI?=0.12?0.06,0.24??,suffering from other chronic diseases???95%CI?=2.39?1.30,3.81??and insufficient physical exercise???95%CI?=-1.10?-2.08,-0.28??.Among the elderly with diabetes,the protective factors of ADL included higher education level???95%CI?=-0.42?-0.71,-0.16??,sufficient physical exercise???95%CI?=-0.55?-0.83,-0.29??,and risk factors included suffering from other chronic diseases???95%CI?=0.51?0.13,0.88??,time???95%CI?=0.25?0.12,0.37??.The risk factors that affected the probability of remaining in or transitioning to the unhealthy state included age???95%CI?=1.34?0.84,1.82??,suffering from other chronic diseases???95%CI?=2.70?1.05,4.33??,time??=4.67?2.63,6.45??,and the protective factors were female???95%CI?=-4.48?-7.67,-1.90??,higher education level???95%CI?=-3.58?-7.11,-0.80??,sufficient physical exercise???95%CI?=-1.84?-2.46,-1.12??.Loss to follow-up caused by death was associated with lower SRH and ADL(??95%CI??ADL?=2.74?1.70,4.07?,??95%CI??SRH?=2.57?1.11,4.07?).The higher risk of death was associated with higher age???95%CI?=0.14?0.02,0.28??,lower education level???95%CI?=-3.16?-5.70,-1.22??,suffering from other chronic diseases???95%CI?=4.07?0.87,8.60??and insufficient physical exercise???95%CI?=-2.25?-4.41,-0.54??.Among the elderly without chronic diseases,the protective factors of ADL included higher education level???95%CI?=-0.55?-1.09,-0.03??,sufficient physical exercise???95%CI?=-0.75?-1.28,-0.20??,and risk factors included suffering from chronic diseases???95%CI?=2.03?1.28,2.87??,time???95%CI?=0.39?0.16,0.61??.The risk factors that affected the probability of remaining in or transitioning to the unhealthy state included age???95%CI?=0.39?0.23,1.08??.Loss to follow-up caused by death was associated with lower SRH and ADL(??95%CI??ADL?=2.29?0.79,3.78?,??95%CI??SRH?=2.64?1.59,3.85?).The higher risk of death was associated with higher age???95%CI?=0.77?0.59,1.00??.The spline curve indicated that among the three groups of the elderly,ADL grew worse with advancing age in both males and females,and the aging effects were similar for males and females.Besides,the analyses of loss to follow-up caused by non-death indicated that the aging effects were statistically significant(??95%CI??Hypertension?=0.30?0.21,0.44?,??95%CI??Diabetes?=0.27?0.20,0.36?,??95%CI??Without chronic diseases?=0.45?0.34,0.58?).?3?In the intervention trial on health management,a total of 347 subjects completed the whole process of follow-up?management,n=155;control,n=192?.According to the results of Bayesian beta mixed models,the significant interaction between time and intervention indicated an increase with time in the management group as compared with the control group on the following dimensions:physical function,ADL,emotional personality,social adaptation,and general health?the 95%CI of coefficients did not include zero?,and no significant change in memory function score was found in the management group?the 95%CI of coefficients included zero?.Conclusions:?1?The situation on HRQoL of the community-dwelling elderly is not optimistic.Chronic diseases as hypertension and diabetes are the main health problems among the community-dwelling elderly.Multimorbidity is common among the community-dwelling elderly and there are some multimorbidity patterns.?2?Health indicators such as ADL and SRH have a certain predictive value for the death of the community-dwelling elderly.The factors of ADL,SRH and death risk may be different among the elderly with different chronic diseases.?3?The multifaceted health management program that integrates a series of health promotion and education activities may be effective in improving the health status of the community-dwelling elderly.Based on the utilization of available resources,specific and feasible targets,health management programs may be implemented as an important measure to improve the health of the elderly. |
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