台北市社區老人之健康概念

Abstract

人口老化使得老年族群成為健康醫療服務的主要使用者，在以個案為中心的概念下，瞭解老人對健康的定義及期待，能幫助加強專業與老人之間的溝通，提升服務的效益。健康概念的發展漸趨全面，回顧最近十年有關不同文化老人的健康概念的研究，結果皆呈現健康定義的多面向架構，曾提及的層面可歸納為生理、功能、行為、心理、靈性及社會，各層面的細節則因其被提出的文化背景而有所差異。台灣過去對老人健康概念的研究不多，加上時代背景的變遷及地域的差異，突顯了需要以貼近現況及融合文化及生活經驗的角度來更深入探討老人健康概念定義之意義。故此，本研究針對台北地區老人，以質性方式探討其健康概念，旨在呈現老年族群在其社會文化背景、生活經驗等的互動中獨特的健康觀點。 有鑑於主題處於探索階段，本研究採用敍事及民族誌學的訪談及觀察等質性方式收集資料，對健康的定義和議題在老人的經驗背境以及文化環境中的意義進行深入探索，配以情境及類屬分析，呈出老人健康概念的建構及內涵意義。研究中以立意取樣輔以按參與者的特性的分層方式，收集到八位居住於台北市的社區老人與健康概相關之資料，當中的質性資料將交替進行情境及編碼分析，並輔以量性資料作對比及補充，再納入華人文化及研究參與之老人的生活經驗共同討論，為所建構的健康概念架構提供脈絡及意義。 透過對八位居住在台北市之社區老人之生命故事探索，發現了與過去研究結果相仿的多層面健康定義，亦根據參與長者對家庭的重視而加入了具華人社會特性之家庭層面。各健康層面在不同長者心目中都有不一樣的定位，它們既可以是目標，也是達到目標的途徑。經常作為最終目標的是生理層面的健康，可見有沒有生病是衡量健康的普遍指標；然而在疾病無法完全避免的認知下，參與者在表達對未來健康的期望時，則根據個人的價值觀而強調功能或其他層面健康。換言之，在長者在面對或預想到健康狀況改變而需要調適的過程中，多層面的健康概念以及層面之間的互動使得他們能更有彈性地訂定或修改健康的目標和達成目標的可行途徑，再落實於他們如何維持健康的實際行動中。此調適過程包括如何選擇出他們重視的目標，並為達到目標而採取的鍛練、節制、維持與外界連接、或休息代償等策略，這除了符合選擇、最佳化、補償(Selection, Optimization, and Compensation, SOC)模式外，也透過較常使用最佳化而相對較少提及補償策略的敍述，反映了參與的長者因其文化背景及生命的經驗—包括華人文化中對長者尊敬的期待、以及過去台灣經歷殖民統治和族群衝突—而對自我形象的重視。再者，也發現長者因對與外界連接的重視程度不同而對於健康的議題的不同重點的解讀，進一步突顯在台灣文化中特有的個體性及社會性不同程度組合對個人價值觀的影響，這樣的理解能幫助我們明白社會事件和人際家庭關係等對長者的意義和價值，從而作為提供符合文化特質及個別化服務的重要基礎。同時，亦發現長者對生命的回顧能作為一整合過程，從中確立自我形象及提升正向感，符合自我延續理論之描述和解釋。上述的每一個環節都能作為醫療健康專業瞭解並與老人共同合作以促進和維護健康的重要考量，從而提供合乎長者期待之服務。

As the population is aging, elderly is now the prime customer group of health care services. Under the concept of client-centeredness, it is important for health professionals to understand the health concepts of lay elderly which may reflect their expectation and need for health care, in order to improve the effectiveness of services provided. The review of health concepts studies among elderly in the past ten years revealed that health concepts of elderly could be organized into a holistic and multidimensional construct. The ever identified dimensions include physical, functional, behavioral, psychological, spiritual and social ones. As can be seen from these studies, not only differences in combination of dimensions were discovered, different details were also identified in each of the six dimensions. Culture and lived experiences were then proposed to be the moderators of health concepts. Few studies have been conducted to explore the health concepts among elderly in Taiwan. Yet, similar results of multidimensional construct were drawn. The contribution made by such study results for the understanding of current health concepts, nevertheless, can be further extended by incorporating the contemporary social context as well as the Taiwanese cultural background and the unique experiences of each elder person. This gives rise to the objective of this study—to explore the health concepts among elderly living in Taipei City within their specific cultural context and lived experiences. In this exploratory stage of study, qualitative study methods of narrative interviewing and ethnographical observations were recruited. The collected data were then subjected to the reciprocal application of context analysis and categorical analysis which helped to identify the interaction of Taiwanese culture and life-course lived experience and unvail the meaning within every story narrated. Supplementary information was also provided by the collection of quantitative data. By having enrolled eight elderly participants aged 65 and above, this study has discovered a similar multidimensional model of health concept as in past studies, while with the emphasis placed on the effect of family relationship to overall health, a cultural-specific family dimension has been insolated from the general social dimension. Another interesting finding was that though an ideal physical health state (physical dimension) was the most frequently mentioned health indicator, functional and other dimensions of health were ready to be the substitute(s) when the physical health declined with age. This can be viewed as an adaptation process enabled by the flexibility inscribed in the multidimensional health model, and directed by individual experiences and cultural values. Such process may involve the consecutive steps of goal selection or reidentification, skills and resources optimization as well as compensation, just as described in the model of Selection, Optimization, and Compensation (SOC). Nevertheless, one should also observed the influence of cultural background, personal experience and values in order to better under the adaptation process and other health related issues, as well as some other special findings of this study (such as the scarce mentioning of using compensation stretigies in adaptation). In the current study, it was found that the history of Taiwan being colonized and going through the continued conflicts among population groups has given rise to the elder people’s expectation of being respected and their need for a well-represented self image. This discovery showed that elder people expect to be connected with the outside world, but in various ways depending on how they value such connection and their corresponding position on the continuum reflecting the constitution of individuality and sociality—a concept proposed to signify the development of Taiwanese consciousness. By perceiving such importance of culture and experiences, health care professionals are able to observe more sensitively the cultural specificity and individuality within one’s health concepts during health care service provision. Furthermore, it is found that life review was able to act as the bridge between personal motive and current environmental resources. This meaning making process can then produce a sense of self continuity which helps to generate and maintain the self concept, sense of integrity, and positive attidutes toward life and future. The integration of the above findings provides an important basis for the collaboration between health professional and elder people so as to fulfill a truly client-centered service.