社区医务人员干预成人超重和肥胖的行为机制及对策探讨

发布时间：2018-05-30 00:04

  本文选题：社区医务人员 + 肥胖　； 参考：《第二军医大学》2017年硕士论文

【摘要】：【研究目的】超重和肥胖已成为我国一项严重的公共卫生问题。社区医务人员是实施体重管理的主体,他们干预超重和肥胖的力度关乎防治工作的成效。国内外研究对社区医务人员群体的关注甚少,尚不清楚当前社区医务人员实施体重干预“执行力度弱、行为水平低”的原因。本研究拟在课题组前期研究工作的基础上,依据已有的社区医务人员干预成人超重和肥胖行为(简称干预行为)的概念框架,建立结构方程模型,明确当前影响社区医务人员干预成人超重和肥胖行为的关键因素及其作用路径,并初步制定促进社区医务人员实施体重管理的干预方案。本研究成果有助于理解社区医务人员从事成人体重管理的行为机制,为今后开展干预研究提供借鉴。【研究内容与方法】本研究分为三个步骤:1、采用Delphi专家函询法和预试验,对课题组前期依据干预行为的概念框架形成的问卷进行检验和修改,以形成一套有效、可靠的调查问卷。2、采用横断面研究,以社区卫生服务中心为单位,按区域分层抽样,实施问卷调查,了解当前社区医务人员干预成人超重和肥胖的现状,分析影响医务人员实施体重管理行为的相关变量,并参照干预行为的概念框架(变量之间的关系结构),构建相应的结构方程模型,进而检验理论假设,明确干预行为的关键变量。3、围绕关键变量,采用文献分析法,拟定推进社区医务人员实施体重管理的措施,形成干预方案初稿;采用专家小组会议修订方案,形成最终建议案。【研究结果】1、问卷信效度检验结果(1)内容效度:通过对13名专家的函询结果,各条目内容效度I-CVI为0.75~0.90,问卷总内容效度S-CVI为0.90。(2)项目分析:各条目的CR值均达到显著性水平。(3)结构效度:各量表因子累计方差贡献率均70%。(4)内部一致性信度:各分量表的Cronbachα系数为0.863~0.950;(5)重测信度(间隔2周):各分量表的组内相关系数为0.307~0.649。正式问卷信、效度良好,包含4个分量表:(1)从事体重管理的行为(8个条目);(2)从事体重管理的知识与技能(9个条目);(3)从事体重管理的感知障碍(8个条目);(4)从事体重管理的态度信念(25个条目)。2、横断面调查结果(n=904)(1)描述性统计结果:(1)社区医务人员实施体重管理行为水平不高,各条目人均得分为1.59~2.18,医务人员最常实施的干预行为是“为患者提供体重相关一般性建议”(2.18±1.05),最少实施的干预行为是“测算腰围”(1.59±0.86);(2)社区医务人员实施体重管理的知识技能掌握程度不佳,各条目人均得分为1.80~2.37,其中掌握最好的是“超重及肥胖可能带来的危害”(2.37±0.63),掌握最差的是“为患者情况制定合理的减重目标及个性化的减重计划”(1.85±0.62);(3)从事体重管理的感知障碍水平较高,各条目的人均得分为4.07~4.82,其中医务人员最认同的障碍为“开展体重干预工作的资金不足”(4.82±1.81)。(2)通过t检验、单因素方差分析、Pearson相关分析筛选变量,析出社区医务人员实施体重管理行为的影响因素,包括:(1)人口统计学因素,如性别、学历、是否出现过体重问题等;(2)职业因素,如专业、职称、知识技能、相关培训经历;(3)态度信念因素,如职业角色认同、环境和资源(障碍感知)、自我效能、结果信念、意向、社会压力、社会支持、权力、习惯/过去行为。(3)路径分析结果:知识和技能可通过影响全科医生/社区护士行为信念影响体重管理行为(间接效应为0.2%/0.4%),也可直接作用于个体行为(直接效应为43.3%/47.6%);社会影响通过影响个体认知或行为意向,间接影响个体行为(总效应为2.1%/9.9%);个体认知,如自我效能(总效应1.4%/2.3%)、职业角色认同(总效应0.3%/9.1%)等通过影响行为意向及习惯/过去行为影响行为。基于上述研究结论形成社区医务人员干预成人超重和肥胖的行为机制模型,最终形成的模型R2为26.3%(全科医生)/25.4%(社区护士),即纳入模型的因素可解释行为水平26.3%/25.4%的变异。模型χ2/df3、GFI、AGFI、NFI、IFI、CFI均大于0.9,RMSEA0.08,各指标提示模型的拟合情况仍较好,各拟合指标均达到了要求。3、形成“促进社区医务人员干预成人超重或肥胖行为的措施”实施方案(1)促进社区医务人员干预成人超重和肥胖的主要措施:(1)加强培训,提高社区医护人员体重管理的知识技能和自我效能感;(2)明确职责,加强督导,提高社区医护人员的干预意愿;(3)提供材料和资源,便于社区医护人员实施体重管理干预;(4)多科室合作,提高体重管理专业性与科学性。(2)效果评价指标及评价时间:(1)医护人员评价指标,如医护人员体重管理行为、医护人员知识技能、医护人员实施体重管理的信念等;(2)患者评价指标,如患者体重、腰围、BMI及患者健康行为;(3)评价时间:实施干预后3个月、6个月、1年等。【研究结论】1、社区医务人员实施成人体重管理的行为水平低,受多种因素影响。其中,知识技能水平和感知的社会支持作为关键因素,可直接影响干预行为水平的高低。2、基于TPB(Theory of planned behavior,计划行为理论)和SCT(Social cognitive theory,社会认知理论)嵌套形式的概念框架,从个体、人际间和社会三个层面揭示了干预行为发生的机制,有助于理解社区医务人员干预体重水平低的原因。3、提高社区医务人员实施体重管理的知识和技能,调动医务人员积极性,是促进社区医务人员干预成人超重和肥胖的重要举措。
[Abstract]:[Objective] overweight and obesity have become a serious public health problem in China. Community medical staff are the main body of body weight management. Their intervention in overweight and obesity is related to the effectiveness of prevention and treatment. Research on the community medical staff at home and abroad is very little, and it is not clear that the current community medical personnel are implemented. On the basis of the previous research work of the group, this study aims to establish a structural equation model based on the conceptual framework of the existing community medical personnel intervened in adult overweight and obesity behavior (intervention behavior), and it is clear that the community medical workers interfere with the overweight and fertilizer of adults. The key factors and the path of action of fat behavior, and the preliminary formulation of intervention programs to promote the implementation of body weight management for community medical workers. The results of this study are helpful to understand the behavior mechanism of community medical staff in adult weight management and provide reference for future intervention research. [research content and methods] this study is divided into three steps: 1, the Delphi expert inquiry method and pre test were used to test and modify the questionnaire formed by the conceptual framework of the intervention behavior in the earlier period, so as to form a set of effective and reliable questionnaire.2, using a cross-sectional study, taking the community health service center as a unit, stratified sampling according to the regional area, and carrying out a questionnaire survey to understand the current community medicine. The staff intervened the status of overweight and obesity in adults, analyzed the relevant variables affecting the behavior of body weight management by medical staff, and constructed the corresponding structural equation model referring to the conceptual framework of intervention behavior (the relationship structure between variables), and then tested the theoretical hypothesis, and made clear the key variable of intervention.3, and adopted the text around the key variables. Analysis method, formulate measures to promote community medical staff to implement weight management, form the first draft of intervention program; adopt the expert group meeting to revise the plan to form the final proposal. [results] 1, the result of the questionnaire and validity test (1) content validity: through the consultation results to 13 experts, the content validity of each item is I-CVI 0.75~0.90, questionnaire The total content validity S-CVI was 0.90. (2) project analysis: the CR values of all items reached significant level. (3) structural validity: the cumulative variance contribution rate of each scale factor was 70%. (4) internal consistency reliability: the Cronbach alpha coefficient of each subscale was 0.863~0.950; (5) retest reliability (interval 2 weeks): the intra group correlation coefficient of each subscale was 0.307~0.649. formal The validity of the questionnaire included 4 subscales: (1) the behavior of body weight management (8 items); (2) knowledge and skills (9 entries) engaged in weight management (9); (3) the perception barrier (8 items) engaged in weight management (8); (4).2, n=904, 1): (1) descriptive statistical results: (1) society The level of body weight management in district medical workers was not high, the average score of each item was 1.59~2.18. The most common intervention of medical staff was "general suggestion of providing weight for the patients" (2.18 + 1.05). The least implementation intervention was "measuring the waist circumference" (1.59 + 0.86); (2) the knowledge of body weight management in community medical staff. The skill mastery was poor, and the average score of each item was 1.80~2.37. The best mastery was "the risk of overweight and obesity" (2.37 + 0.63). The worst mastery was "a reasonable weight reduction target and a personalized weight reduction plan for patients" (1.85 + 0.62); (3) the level of perception barriers in body weight management was higher, The average per capita score was 4.07~4.82, and the most recognized barriers for medical staff were "insufficient funds to carry out weight intervention" (4.82 + 1.81). (2) through t test, single factor analysis of variance, and Pearson correlation analysis, the factors affecting the implementation of body weight management in community medical staff were analyzed, including: (1) demographic factors, such as Gender, educational background, weight problems, etc. (2) occupational factors, such as professional, professional, knowledge and skills, related training experience; (3) attitude and belief factors, such as professional role identity, environment and resources (barrier perception), self-efficacy, belief, intention, social pressure, social support, power, habit / past behavior. (3) path analysis results: Knowledge: knowledge And skills can affect body weight management behavior by affecting the behavior beliefs of general practitioners / community nurses (the indirect effect is 0.2%/0.4%), and can also directly affect individual behavior (direct effect is 43.3%/47.6%); social influence indirectly affects individual behavior (the total effect is 2.1%/9.9%) by influencing individual cognition or behavioral intention; individual cognition, such as self effect, is influenced by the social influence. Ability (total effect 1.4%/2.3%), professional role identity (total effect 0.3%/9.1%) and other behaviors affecting behavior intention and habit / past behavior. Based on the above conclusions, a model of behavior mechanism for community medical staff to interfere with overweight and obesity is formed, and the final model R2 is 26.3% (general practitioner) /25.4% (community nurse), namely the model of inclusion model. The factor of type can explain the variation of behavior level 26.3%/25.4%. Model chi square 2/df3, GFI, AGFI, NFI, IFI, CFI are all greater than 0.9, RMSEA0.08, the fitting of each index model is still better, each fitting index has reached the demand.3, forming "measures to promote community medical staff to intervene the behavior of overweight or obesity" (1) promote the community The main measures for medical staff to interfere with overweight and obesity: (1) strengthen training, improve the knowledge skills and self-efficacy of the body weight management of the community medical staff; (2) clear responsibilities, strengthen supervision, improve the intervention will of the community medical staff; (3) provide materials and resources to facilitate community health care workers to implement weight management intervention; (4) multidisciplinary integration To improve the professional and scientific nature of weight management. (2) the evaluation index and time of effect evaluation: (1) the evaluation indexes of medical and nursing staff, such as the behavior of body weight management, the knowledge and skill of medical staff, the belief of the medical and nursing staff to carry out the weight management; (2) the evaluation of patients' weight, waist circumference, BMI and patient's health behavior; (3) evaluation time: 3 months, 6 months, 1 years after the implementation of the intervention. [Conclusion] 1, the behavior level of the community medical staff in the implementation of adult weight management is low and affected by many factors. Among them, the level of knowledge skills and perceived social support can directly affect the level of intervention behavior, based on TPB (Theory of planned behavior, plan). Behavior theory) and the conceptual framework of nested form of SCT (Social cognitive theory, social cognition theory), which reveal the mechanism of intervention from three levels of individual, interpersonal and social, and help to understand the cause of community medical staff to interfere with the low level of weight,.3, the knowledge and skills of carrying out weight management in community medical staff. The initiative of medical staff is an important measure to promote community medical personnel to intervene in overweight and obesity in adults.
【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R473.2

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