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題名：從老人居住安排及未滿足需求論我國長期照顧政策
作者：陳正芬 引用關係
作者(外文)：Chen-fen Chen
校院名稱：國立中正大學
系所名稱：社會福利所
指導教授：王正
學位類別：博士
出版日期：2006
主題關鍵詞：生命週期；居住安排；長期照顧；未滿足需求；資源轉變；老人福利；Elderly welfare；Resource change；Unmet need；Life-cycle；Living arrangement；Long-term care
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我國老人人口自1993年達到聯合國世界衛生組織所訂之高齡化社會指標後，釵h研究即針對台灣社會的變遷與傳統家庭觀的改變，再加上因就業或就學而導致的城鄉遷移等趨勢提出警告，認為父母與子女同住的家庭制度與弁銃}始崩解，主張政策取向應透過鼓勵方式維繫老人與子女同住的居住模式，並發展多元服務模式滿足失能老人之照護需求。然而，國內有關老人居住安排決定的研究並不豐富，且其中對於老人居住安排及老人家戶結構的瞭解大都來自橫斷面研究結果，探討現代化與都市化的台灣社會脈絡下一般健康老人的居住安排因素，無法對處於生命週期末段的失能老人之居住安排及照顧需求提供進一步資訊。據此，本文預期能藉由理解該老人居住安排變遷下的真實內涵，檢視社區老人之未滿足需求盛行率及影響因素，進而規劃適當的長期照護政策以維持家庭照顧與正式照顧體系的平衡關係，促使失能老人之照顧需求獲得適切的滿足。
為檢視居住安排、健康狀況與照顧來源的關係，本研究將克服以前研究在研究資料及研究方法上的限制，除將人口特性、健康及經濟相關因素納入模型，並納入之前的居住安排狀況以及健康及經濟等動態變項，從一動態觀點分析我國老人居住安排的長期趨勢與影響因素，並依據不同居住安排模式探討社區老人所獲得之照顧支持以及未滿足需求；研究資料來自行政院衛生署家庭計畫研究所於1989年至1999年間舉辦的四次「台灣地區中老年身心社會生活狀況長期追蹤調查」資料，研究樣本為3893位居住於社區中年滿60歲的老人；該項調查為國內第一個有全國代表性關於老人生活狀況的固定樣本追蹤調查。以SPSS 12.0版 for windows、SAS 8.2版及STATA軟體進行各項統計分析，過程中以SAS 8.2版將四波資料合併，採用GEE（General Estimation Equation）方式進行係數的估計，檢視自變項與依變項之相關，再以層級多項邏輯迴歸（hierarchical multi-nominal logistic regression model）進行分析。
研究結果顯示與已婚子女同住仍是我國老人最偏好且最穩定的居住模式，顯示我國多數老人係以「預期事件」為居住安排的主要考量，預期透過家庭結構的擴大因應生命週期末端可能發生的風險事故；事實上，即使該類居住模式的老人遭遇健康狀況惡化等狀況，大多數人仍維持原居住模式；但選擇「獨居」或「僅與配偶同住者」的居住模式則受到「突發事件」影響較大，也就是當其工具性生活自理能力（IADLs）喪失或面臨喪偶等生命重大事件時，其會透過居住安排的改變尋求照顧來源；相較於美國老人以ADLs活動嚴重失能為居住安排改變的決策參考，我國老人似乎將IADLs障礙當作個人健康的一項警訊，且透過居住安排的改變予以回應，顯示其回應步調比西方老人更早。再者，經濟資源亦是老人居住安排的顯著影響變項，但所得與子女同住的比例並非呈現反比關係，本研究主張經濟資源應被視為老人可依其偏好選擇居住方式之機會成本。
為瞭解弁鉬棆爬悀H之ADL與IADL未滿足需求盛行率，並探討可能影響未滿足需求的相關因素，本研究將「居住安排」視為非正式支持網絡的結構，將「未滿足需求的表達」當作網絡支持弁鄋澈苤A假設老人未滿足需求的表達會因居住安排（結構因素）及照顧網絡的組成（弁鄏]素）而有差異。研究結果發現居住安排固然是未滿足需求的顯著影響變項，獨居者幾乎等同是未滿足需求的高危險群，但其中仍有三分之一的老人並未表達未滿足需求，顯示獨居老人的異質性應亦被相對重視。其次，雖然多數失能老人的照顧仍來自非正式支持網絡，但約有三成的社區老人都曾經有發生未滿足需求的經驗；特別是由配偶擔任照顧者時，失能老人表達未滿足需求的比例相對較高，意謂老人照顧老人的情況值得關注！
本研究從老人的角度出發，檢視老人在家庭主義及國家意識型態夾縫間獲得照顧現況，發現單靠老人之非正式支持體系及代間交換力量已不足以完整滿足弁鉬棆爬悀H之照顧需求，爰此，我國長期照顧政策不應強調老人與子女同住之必要性，假設子女與老人共居的家戶才是理想的家庭型態；而是應以老人本身所在的家戶為長期照顧服務提供的單位，盡可能將服務輸送到老人所在家戶，避免讓老人遷就照顧現實而不得不進行晚年居住安排的遷移；另一方面除肯定家庭是照顧老人的重要資源，亦應針對家庭照顧不足面向予以補充與支持，投注適當且充足的資源來支持家庭照顧，方能促使家庭照顧能力得以維持，且能確保老人在任何家戶型態下將可獲得照顧需求的滿足。
In 1993, the proportion of aged population in Taiwan reached 7%, which has been defined as the benchmark of aging society by World Health Organization. Since that time, many researchers had warned that the decline of traditional family value and the internal migration would lead to the deconstruction of the existing institution of co-residence of elder parents with adult children. They had also suggested that the government should establish policies to encourage people to maintain such co-residence, and provide multiple modes of long-term care services to meet the various needs of disabled elderly people. However, now, in Taiwan, the existing studies focused on elderly people’s living arrangement are not abundant. Most of them explain elderly people’s living arrangement and household structure, only based upon cross-sectional data. Thus, they can just deal with the factors influencing healthy elderly people’s living arrangements under the social context of modernization and urbanization in Taiwan. They are unable to further answer how disabled elderly people decide their living arrangements and what care services they need during their final life cycle phase. Accordingly, my study attempted to explore the implications of the transition of elderly people’s living arrangements. I tried to apply such implications to examine the prevalence and the influencing factors of elderly people’s unmet needs in community. This examination would help the future long-term care policy to keep the balance between family and formal care system. I thought such balance could promote the satisfaction of disabled people needs for care services.
In order to examine the relationship among living arrangement, health status and care sources, my study attempted to overcome the limitation of data and analysis methods. Not only population characteristics, health status, and economic resources were included into my study model, but also the previous living arrangement and time-dependent co-variation of health status and economic resources were introduced. I tried to apply a dynamic approach to analyze the transition of living arrangements and the relevant factors, and explore elder people’s met and unmet needs for care services based upon different living arrangement. The data sourced from a national survey of over 3,893 men and women of age 60 above in Taiwan, which was conducted by National Institute of Family Planning, Department of Health, Executive Yuan, in 1989, 1993, 1996, and 1999, and which was the first nationally representative panel survey of elderly people life situation. Three time-intervals were pooled to depict the transitions in living arrangements between 1989 and 1999. Hierarchical multinomial logistic regressions were used to analyze the effects of baseline health and health changes on living arrangements and their transitions.
The results of my study show that living with married children was the most prevalent and stable arrangement among elderly Taiwanese. It is because that most old people selected living arrangements mainly based upon the “remote thoughts”, and planned to conquer the risk event in the end of life cycle through the enlargement of family structure. Eventually, though the elderly people who selected to “live with married children” sill maintained the previous living arrangement even after their health got worsen, those who selected to “live alone”, or “only live with spouse” were being impacted much more by “the accident”. It means that elderly people who lost their abilities of IADLs, became widowed, or were confronted with other important life events would look for care resources through the transition of living arrangement. In contrast with that elderly Americans tend to view disabilities of ADLs as the reference to the decision of changing their living arrangement, the elderly people in Taiwan appear to take the disabilities of IADLs as a warning of personal health problem, and to respond such warning through the transition of living arrangement. This contrast shows that the elderly people in Taiwan respond the change of health status more immediately than in Western. Moreover, besides health status, economic resource variables were the key factors influencing living arrangements. But elderly people’s willingness to live with married children was not in inverse proportion to their income level. Hence, I believe that economic resources should be considered as the opportunity cost that could support elderly people for choosing living arrangements based on the preference.
Furthermore, to assess the prevalence of unmet needs in ADLs and IADLs, and identify the relevant factors of unmet needs, my study regarded “living arrangements” as the structural indicator of informal support networks, and considered “the expression of unmet needs” as the functional indicator of the function of support networks. I supposed that living arrangements (structural indicators) and care networks (functional indicators) were the important predictors of unmet needs. The results indicate that the elderly people who lived alone were the high-risk group of unmet needs. However one third among them had not expressed the unmet needs. It shows that the heterogeneity of live- alone-elderly people deserve our attentions. Secondly, though most disabled elderly people received the care services provided from informal support network, it was about 30% among the elderly people in the community that had once experienced the situations of unmet needs. Especially when their spouse as the caregiver, the proportion of the disabled elderly who expressed unmet needs were relatively high. It implies that the situation of elderly-cared-by-elderly deserved more attentions!
In general, my study stood on the position of elderly people to examine the care services elderly people received under the double pressure of familism and statism. I found that it could not anymore satisfy the demands of elderly population for care services to depend wholly upon informal support networks and the intergenerational exchange. In conclusion, our long-term care policy shouldn’t emphasize the necessity of the co-residence with children, and insist such living arrangement as the ideal style of family. On the one hand, the government should regard the elderly people’s living-household as the unit of care provision, try its best to supply the care services to the household where elderly people was living, and prevent elderly people from the transition of living arrangements for receiving care services during the final life cycle phase. On the other hand, the government should also provide the supplements and supports to family care system. Thus, family will keep its abilities to provide elderly people with quality care services. If only so, the care needs of elderly people in different living arrangements will be all met.
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