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结核病患者遵医行为影响因素研究及评定量表研制

发布时间:2018-05-08 03:17

  本文选题:结核病 + 依从性 ; 参考:《华中科技大学》2013年博士论文


【摘要】:研究目的 本研究主要针对目前结核病患者遵医行为测量的研究空白,通过现场调查对影响结核病患者遵医行为的一系列因素进行筛选、验证,最终建立准确、有效的结核病患者遵医行为评定量表。 研究方法 本研究首先通过查阅文献和小组访谈了解结核病患者遵医行为研究现状和可能的影响因素,在此基础上设计调查问卷初稿。课题组通过预调查对问卷进一步小幅度修改后于2010年9月至2011年8月期间在武汉市江汉区和xZ口区23家社区卫生服务中心对所有确诊在管的结核病患者进行一对一现场调查。社区卫生服务中心结核病防治工作人员对患者进行现场调查后,对患者的取药记录进行随访登记,根据取药记录计算患者药物空白时间比例(continuous multiple-interval medication gaps, CMG)定量判断患者遵医行为的好坏。调查数据收集整理后,应用均数、标准差、中位数、构成比等对患者基本特征和可能的依从性影响因素进行描述性分析,应用多因素Logistic回归分析在控制其它因素的情况下,确定患者依从性的影响因素。研究主要应用分辨力系数、相关分析以及探索性因子分析对量表条目进行筛选。量表信度主要应用克朗巴赫系数、分半信度及重测信度进行评价。量表效度主要应用内容效度、结构效度、聚敛效度和标准关联效度进行评价。应用ROC曲线分析对量表的预测价值进行评价并确定量表的诊断界值,在此基础上对量表和CMG的诊断结果做一致性分析,计算量表灵敏度、特异度、阳性预测值和阴性预测值。最后采用多因素Logistic回归分析和路径分析研究量表各维度与遵医行为之间的关系。 以上所有分析均在使用EpiData3.0软件进行数据双录入后,使用Amos20.0进行证实性因子分析和路径分析,应用SAS9.2软件进行其它统计分析。在数据分析过程中,对调查表中的缺失值以相应条目的中位数值替换。 结果 1、结核病患者遵医行为现状与影响因素分析。研究中共调查438名结核病患者,平均年龄为39岁,男性占68.04%。根据CMG判断标准,调查对象中有不遵医行为的人数为181,不遵医行为发生率为41.32%。多因素分析显示患者年龄、文化程度和婚姻状况与其遵医行为没有明显相关性。相对于年龄小于20岁的患者,年龄在40~60岁之间的患者更倾向于不遵医,OR值为0.25(95%CI:0.09~0.71)。卫生服务可及性、医患交流、患者行为特点、患者心理特点、患者对疾病态度以及社会支持与患者遵医行为有显著相关性。 2、结核病患者遵医行为评定量表的研制。量表包含有九个维度30个条目,九个维度分别为医患交流、行为特点、治疗信心、社会支持、心理状况、生活习惯、应对方式、记忆力以及卫生服务可及性。量表的克朗巴赫系数、重测信度和分半信度分别为0.87、0.83和0.85。量表9个维度的信度分别为0.88、0.78、0.73、0.75、0.67、0.78、0.77、0.51和0.52。Pearson相关分析显示量表总分与每个维度的得分有显著性相关(P0.001)提示TBMAS有较好的内容效度。量表总分及每个维度得分与患者取服药记录有显著性相关显示其具有好的聚敛效度和标准关联效度。量表30个条目证实性因子分析后的因子载荷都大于0.4,结构方程模型拟合评价指标GIF、CFI及RMR值等显示模型拟合良好,综合说明了量表的结构效度较好。ROC曲线分析显示曲线下面积为0.82(95%CI:0.77-0.86),量表总分取113为界值点时,量表灵敏度和特异度分别为82.9%和69.3%,阳性预测值和阴性预测值分别为65.5%和85.2%。 3、结核病患者遵医行为评定量表各维度与遵医行为关系研究。多因素Logistic回归分析显示患者在量表九个维度得分大于相应界值时,量表九个维度所反映的影响因素对促进患者遵医行为有保护作用,反之则为危险因素。路径分析显示治疗信心、心理特点和生活习惯对患者遵医行为只有直接影响,其标准化影响效应分别为0.36、0.16和0.11。医患交流、社会支持对患者遵医行为既有直接影响也有间接影响,总的影响效应为0.30和0.27。行为特点、应对方式、记忆力和卫生服务可及性对遵医行为的影响主要为间接影响,影响效应分别为0.19、0.18、0.14和0.09。 结论和建议 结核病患者服药依从性较差。结核病患者遵医行为评定量表具有可靠的信度和效度,可以被结核病防治工作者用作判断患者依从性的一个有效工具。结核病患者年龄和婚姻状况与遵医行为没有明显相关,患者文化程度在单因素分析时与遵医行为呈正相关,40~60岁年龄段患者比其他年龄段患者不遵医的危险性增加。患者治疗信心对遵医行为影响最大,其次为医患交流和社会支持,其它因素主要通过这三个因素对遵医行为产生影响。 有必要在其他地区对结核病患者遵医行为评定量表的信度、效度及使用价值开展进一步实践研究。在DOTS策略实施的过程中需要重视患者实际服药的依从性,可以考虑根据患者的遵医行为对其实施科学的分类管理。医务人员应该加强与患者的交流,提高患者治疗结核病的信心。 创新和局限性 首先,本研究紧密跟踪结核病防治这一热点研究领域,但并不是重复国内外其他学者的研究工作,而是从国际该领域前沿出发,从研究结核病患者的遵医行为入手,,对DOTS策略的技术要素DOT提出改进的科学依据,并建立实用行强的测量工具,有可能对DOTS策略的深化和改良起到实质性的促进作用。另外,本研究成功研制了第一份专门针对结核病患者遵医行为的评定量表,该量表在发现不遵医患者的同时还能筛选出影响该患者不遵医的危险因素,是一项极具开拓性的尝试。从卫生管理学的角度分析,本研究是管理策略研究从卫生政策研究向疾病防治实践研究的深化,是一种开拓性探索。 本研究的局限性主要体现在两个方面。首先,结核病患者遵医行为评定量表设计研制时的调查人群都为武汉市城区结核病患者,尚需在更多地区尤其是农村地区实践后进一步验证其科学性和实用性。另外,研究中采用CMG值作为判断患者依从性好坏的主要标准,虽然CMG值是一个客观的综合测量患者服药情况的指标并被学术界所认可和广泛使用,但是该指标不能判断患者拿药之后是否按时按量服用,因此有必要采用更加客观准确的方法研究结核病患者遵医行为,并对量表效度进行评价。
[Abstract]:research objective
This study is mainly aimed at the research blank of the measurement of compliance behavior of tuberculosis patients. Through the field investigation, a series of factors affecting the compliance behavior of TB patients are screened and verified. Finally, an accurate and effective assessment of the compliance behavior of TB patients is established.
research method
First of all, the first draft of the questionnaire was designed on the basis of consulting literature and group interviews to understand the status and possible influencing factors of the study on the compliance of TB patients. 23 community guards in Jianghan District and xZ District of Wuhan were in the period from September 2010 to August 2011. All patients who were diagnosed with tuberculosis were investigated in a one to one field survey. The TB control staff in the community health service center conducted a field survey on the patients, followed up and registered the records of the patients' drug withdrawal records, and calculated the proportion of drug blank time (continuous multiple-interval medicati) according to the record of drug withdrawal. On gaps, CMG) quantified the patient's compliance behavior. After the survey data were collected, the application average, standard deviation, median, composition ratio, and other factors of the patient's basic and possible compliance were descriptive and analyzed. Multiple factor Logistic regression analysis was used to determine the patient compliance under the control of other factors. The main application of resolution coefficient, correlation analysis and exploratory factor analysis was used to screen the items of scale. The reliability of the scale was mainly evaluated by Krone Bach coefficient, semi reliability and retest reliability. The validity of the scale, structural validity, convergence validity and standard validity were evaluated. The application of ROC The predictive value of the scale was evaluated by curve analysis and the diagnostic boundary value of the scale was determined. On this basis, the diagnostic results of the scale and CMG were analyzed, the sensitivity, specificity, positive predictive value and negative predictive value of the scale were calculated. Finally, multi factor Logistic regression analysis and path analysis were used to study the dimensions of the scale and compliance. The relationship between them.
All of the above analyses are performed using EpiData3.0 software for data double entry, using Amos20.0 for confirmatory factor analysis and path analysis, and using SAS9.2 software for other statistical analysis. In the process of data analysis, the missing values in the questionnaire are replaced by the corresponding median value.
Result
1, analysis of the status and influencing factors of compliance behavior of tuberculosis patients. A total of 438 tuberculosis patients were investigated with an average age of 39 years. The male accounted for 68.04%. according to the CMG criterion. The number of non compliance behaviors was 181, and the incidence of non compliance was 41.32%. polyin analysis showing the age, educational level and marital status of the patients. There was no significant correlation between the situation and the practice of compliance. Compared with patients younger than 20 years old, patients aged 40~60 were more inclined to not comply with medical treatment, OR value was 0.25 (95%CI:0.09~0.71). Health service accessibility, medical and patient communication, patient behavior characteristics, patient psychological characteristics, patients' attitude to disease, social support and patient compliance behavior. There is a significant correlation.
2, the scale of compliance assessment of tuberculosis patients was developed. The scale contained nine dimensions and 30 items, and nine dimensions were medical communication, behavioral characteristics, treatment confidence, social support, psychological status, lifestyle, coping style, memory and accessibility of health service. The Krone Bach coefficient, retest reliability and half reliability score of the scale. The reliability of the 9 dimensions of the 0.87,0.83 and 0.85. scales was 0.88,0.78,0.73,0.75,0.67,0.78,0.77,0.51 and 0.52.Pearson correlation analysis respectively. The total score of the scale was significantly correlated with the score of each dimension (P0.001) suggesting that TBMAS had better content validity. The total score of the scale and the score of each dimension were significantly related to the patient's record of taking medicine. It showed that it had good convergence validity and standard correlation validity. The factor load of the 30 items proved that the factor load was more than 0.4 after the confirmatory factor analysis. The model fitting evaluation index GIF, CFI and RMR values were well fitted, and the structure validity of the scale was better than that of the.ROC curve analysis display area of 0.82 (95%CI 0.77-0.86), the sensitivity and specificity of the scale are 82.9% and 69.3% respectively, and the positive predictive value and negative predictive value are 65.5% and 85.2%., respectively, when the scale is divided into 113 boundary points.
3, the relationship between the dimensions of the compliance assessment scale and the compliance behavior. Multiple factor Logistic regression analysis showed that when the score of the nine dimensions of the scale was greater than the corresponding boundary value, the factors reflected by the nine dimensions of the scale were protective for promoting the patient's compliance, and the contrary was the risk factor. The treatment confidence, psychological characteristics and living habits have only direct influence on patients' compliance with medical compliance. Their standardized effects are 0.36,0.16 and 0.11., respectively, and social support has both direct and indirect effects on patients' compliance behavior. The total effects are 0.30 and 0.27., coping style, memory and health services are available. The influence of sex on medical compliance is mainly indirect effect, and the effect is 0.19,0.18,0.14 and 0.09. respectively.
Conclusions and suggestions
The compliance of TB patients with drug compliance is poor. The compliance assessment scale of TB patients has reliable reliability and validity, and it can be used as an effective tool to judge patient compliance. The age and marital status of TB patients are not significantly related to compliance, and the degree of patient culture is in a single factor analysis. There was a positive correlation with compliance behavior. The risk of non compliance in 40~60 age groups was higher than those of other age groups. Patients' confidence in treatment had the greatest impact on compliance, followed by medical communication and social support. The other factors were mainly influenced by these three factors.
It is necessary to carry out further practical research on the reliability, validity and use value of the compliance assessment scale of tuberculosis patients in other areas. In the process of implementing the DOTS strategy, the compliance of the patients' actual medication should be paid more attention to, and the scientific classification management can be considered according to the compliance behavior of the patients. Medical personnel should strengthen the practice. Patients' communication will enhance their confidence in treating tuberculosis.
Innovation and limitations
First of all, this research is closely following the hot research field of tuberculosis control, but it does not repeat the research work of other scholars at home and abroad, but starting from the frontier of the international field, starting with the study of the compliance behavior of tuberculosis patients, the scientific basis for improving the technical element DOT of the DOTS strategy is put forward, and a practical and practical measuring worker is set up. It has the potential to contribute to the deepening and improvement of the DOTS strategy. In addition, this study has successfully developed the first assessment scale for the compliance behavior of tuberculosis patients. The scale can also screen out the risk factors that affect the patient's non compliance, which is a very pioneering taste. From the point of view of health management, this study is a pioneering exploration of the research of management strategy from the research of health policy to the practice of disease prevention and control.
The limitations of this study are mainly embodied in two aspects. First, the population of the tuberculosis patients who have been designed and developed for the assessment of the compliance behavior of tuberculosis patients are all tuberculosis patients in Wuhan City, and it is still necessary to further verify its scientificity and practicability in more areas, especially in rural areas. In addition, the CMG value is used to judge patients in the study. The main standard of compliance is that the CMG value is an objective and comprehensive measure of the patient's medication and is recognized and widely used by the academic community. However, the index can not judge whether the patient is taking the drug on time after taking the medicine. Therefore, it is necessary to use a more objective and accurate method to study the compliance behavior of the patients with tuberculosis. The scale validity was evaluated.

【学位授予单位】:华中科技大学
【学位级别】:博士
【学位授予年份】:2013
【分类号】:R52

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