肺结核风险传播干预与效果评估
发布时间:2018-04-03 03:31
本文选题:肺结核 切入点:风险传播 出处:《华中科技大学》2013年博士论文
【摘要】:我国是全球22个结核病流行严重的国家之一,结核病负担全球第二。流动人口肺结核是当前中国结核病控制的一大难题,病例发现不及时、肺结核患者跨区域流动是肺结核高治愈率背景下提高结核病控制质量的瓶颈。 风险传播,是个体、群体以及机构之间交换有关风险的信息、意见和看法的互动过程。风险传播应用于临床医疗领域,主要是医患之间分享和讨论有关医疗服务或健康行为利弊的信息,在个体化风险信息的基础上进行沟通,帮助患者选择某项医疗服务或改变不良行为。 本文在深圳市南山区采用风险传播,在双向沟通、患者充分知情、提醒及激励的前提下,调动肺结核患者的自主能动性,促进肺结核病例的发现、实现跨区域转诊患者治疗的延续性,尝试肺结核控制领域新难题的突破。 第一部分普通人群肺结核风险认知和病耻感 目的:风险认知是指人们对风险性质和严重程度的主观判断,是采取健康行为或改变不良行为习惯的重要动力;肺结核病耻感指因患肺结核经历过或者预期受到负面对待,而产生的被排斥、拒绝、责难、贬低以及羞耻、有罪的个体体验,也是一种社会现象,是患者延迟就诊和治疗不依从的重要影响因素。本部分将掌握居民对肺结核的风险认知和病耻感现状,为肺结核患者相关健康行为(接触者筛查、就诊、治疗等)干预提供基础。 方法:通过分层抽样方法,对在社区健康服务中心就诊的492名非肺结核患者进行问卷调查。 结果:调查对象肺结核相关知识知晓率为82.0%;肺结核严重性认知6.9分(1-10分范围,为调查的八种疾病/状况的中间水平)、可能性认知为3.1分(1-10分范围,排在倒数第三位),总风险认知为2.1分(1-5分范围,所有疾病/状况风险认知水平接近);同时结果提示大众存在一定的乐观或侥幸心理,54.9%认为自己比别人患肺结核的可能性小。调查显示,肺结核外部病耻感22.6分(0-50分范围),主要表现为与肺结核患者保持距离;内部病耻感总分为20.8分(0-50分范围),其中“别人会避开我”、“配偶或男女朋友不会与我同住”、“别人会瞧不起我”以及“即使治好了找工作都很困难”为前四项;负面情绪(紧张、害怕和担心)得分为3.6分(1-5分范围)。 研究表明,肺结核知识与内部病耻感、严重性认知正相关(r分别为0.11和0.13),与易感性和风险认知及外部病耻感无相关关系;外部病耻感与严重性认知正相关(r=0.14),与易感性和风险认知负相关(r分别为-0.21、-0.13);而内部病耻感只与严重性认知正相关(r=0.18);病耻感两部分之间正相关(r=0.52);负面情绪与外部、内部病耻感正向中度相关(r介于0.37-0.43之间),与严重性认知正向弱相关(r介于0.12-0.16之间)。 结论:被调查的居民肺结核相关知识知晓率达到卫生部“十一五”结核病防治规划要求,对于肺结核的风险认知与对慢性疾病(艾滋病、心梗、高血压、糖尿病)、急性疾病或状况(禽流感、普通感冒、食物中毒)的水平相当,存在肺结核的病耻感和负面情绪。 第二部分传染性肺结核患者密切接触者筛查风险传播干预 目的:密切接触者筛查是主动发现肺结核患者的有效手段,但在我国不被重视。本部分将探讨实施风险传播综合干预对提高肺结核患者配合度,促进其密切接触者接受临床筛查、提高肺结核病例发现的作用。 方法:以南山区2011年登记管治的15周岁以上的传染性肺结核患者(涂阳、培阳和涂阴空洞)为研究对象,以其登记管治月份为单位将其分为干预和对照组(285名患者参与,其中对照组135人,干预150人);对照组则按照国家结核病控制指南实施常规筛查——接受门诊医师口头问询,督导医师不参与;干预组采用督导医师强化宣教、发放筛查预约单、短信提醒及经济激励等综合干预措施。 结果:干预组病人调查阶段共识别623名密切接触者,平均每名患者4.2名,高于国家指南预期的3名(P0.001);风险传播干预组有密切接触者到位的患者比例为36.7%(55名),远高于对照组9.6%(13名)(OR=3.304,P=0.001);平均每名患者密切接触者筛查数,风险传播干预及对照组分别为0.7和0.1(IRR=3.205,P0.001)。经临床检查,干预组发现31名肺结核病例(其中2名临床确诊患者、29名结核菌隐性感染),对照组只发现了7名结核菌隐性感染;对于每名患者发现二代肺结核病例来说,两组差异具有统计学意义(0.2VS0.1,P0.001)。患者中推荐密切接触者的意愿平均为72.3%,其中推荐家人筛查意愿最高(91.7%);推荐密切接触者筛查障碍中,预期会丢失工作、其他人会远离自己及失去经济来源排在前三位。 结论:通过督导医师强化宣教、发放筛查预约单、短信提醒及经济激励等干预措施促进了患者推荐其密切接触者接受筛查,提高了密切接触者识别和病例发现;患者内心耻辱感是影响患者推荐的障碍。在保障患者工作权、平衡患者隐私权与他人健康权等的前提下,如何有效开展流动人口密切接触者筛查,以及提高密切接触者配合度的措施,是今后进行研究的问题。 第三部分流动人口肺结核患者跨区域转诊风险传播干预 目的:跨区域转诊现象在确诊的流动人口肺结核患者中经常发生,容易造成患者治疗不规范甚至中断治疗,给肺结核控制带来很大困难;中国肺结核跨区域转诊率虽只有3%,却占据治疗效果不理想(死亡、治疗失败、丢失等)的一半。本部分将研究风险传播措施在提高流动人口肺结核患者治疗的连贯性与治愈率的作用。 方法:以南山区内登记管治的流动人口肺结核患者为对象,采用干预前后对照类试验方法;2007年10月-2008年9月(干预前)采用全球基金《跨区域肺结核患者管理程序》的方法;2008年10月-2009年9月(风险传播干预一期),执行包括“以提高患者治疗依从性的强化健康教育和医患交流、治疗期强化监督、跨区域转诊协助及追踪和加强转入地密切联系”在内的综合干预;2009年10月-2011年9月(风险传播干预二期),在干预一期基础上加强对转入地结核病防治机构干预,建立了与全国绝大部分县市机构的QQ联络平台,实时与转入地联络(提醒对方落实转出患者的转诊追踪,与其工作人员交流“中国疾病预防控制系统-转诊管理”的操作),采用经济激励措施(转入地采取“代管”方式管理患者,则转给结核病防治机构代管病人管理费)。 结果:南山区4年共管治流动人口肺结核患者2244名,总转出率为17.1%,其中干预一期、干预二期转出率分别为18.5%(110名)、16.1%(179名),与干预前转出率17.5%(94名)接近(P=0.439)。干预前,只有39.4%的患者离深时提前告知医务人员,,干预一期上升到61.8%,二期达到86.5%,年均增幅为30.0%(P0.001);转诊到位率从51.1%提升到2011年的85.5%,年均增幅为18.7%;四年内重登率绝对值下降了69%,年均降幅为32.1%;转出患者治愈或完成治疗率从4.3%增长到59.8%,但低于流动人口患者整体治愈率(86.0%)。 结论:跨区域转诊管理风险传播综合干预措施-强化健康教育与医患交流、疗程关键点监管、转诊协助及与异地结核病防治机构交流沟通,能提高流动人口肺结核患者治疗的连贯性与治疗效果,但是不能减少患者转诊的发生;需要加强对流动人口的关怀、减少肺结核患者的经济负担。 创新性: 1.以定量的方法测量居民肺结核风险认知和病耻感现状,并分析它们的相关性; 2.应用风险传播方法针对肺结核防治的瓶颈问题——肺结核病例发现不及时、流动人口跨区域转诊——进行干预,并有一定的突破,如促进了传染性肺结核密切接触者筛查的实施、提高了病例早期发现数和实现了流动人口跨区域患者治疗的延续性。
[Abstract]:Our country is one of the world ' s 22 tuberculosis epidemic countries , the tuberculosis burden is the second . Floating population pulmonary tuberculosis is a major problem of tuberculosis control in China . The case has found that the cross - regional flow of tuberculosis patients is the bottleneck of improving the quality of tuberculosis control in the background of high cure rate of pulmonary tuberculosis .
Risk communication is an interactive process of exchanging information , opinions and views among individuals , groups , and agencies on risks . The spread of risk is applied to the clinical medical field , mainly in the sharing and discussion of information about the advantages and disadvantages of medical services or health behaviors among doctors and patients , and communication on the basis of personalized risk information to help the patient select a medical service or change bad behavior .
In this paper , the risk communication is adopted in the southern mountain area of Shenzhen . In the premise of two - way communication , patient ' s knowledge , prompt and encouragement , the self - initiative of patients with pulmonary tuberculosis is mobilized , the discovery of pulmonary tuberculosis cases is promoted , the renewal of treatment of transregional referral patients is realized , and the breakthrough of new challenges in the control of pulmonary tuberculosis is attempted .
The Risk Perception of Pulmonary Tuberculosis in the First Part and the Sense of Disgrace
Objective : Risk perception refers to the subjective judgement of the nature and severity of risk , which is an important motive force to take health behavior or change bad behavior habit .
Pulmonary tuberculosis is a social phenomenon , which is a social phenomenon , which is a social phenomenon , which is a social phenomenon , which is an important factor affecting the patient ' s delayed visit and treatment . This part will grasp the residents ' awareness of the risk of pulmonary tuberculosis and the status quo of disease and shame , and provide the basis for the intervention of the related health behavior of patients with pulmonary tuberculosis ( contact screening , treatment , treatment , etc . ) .
Methods : 492 non - pulmonary tuberculosis patients who visited the community health service center were investigated by stratified sampling .
Results : The knowledge rate of tuberculosis - related knowledge was 82.0 % .
The severity of pulmonary tuberculosis was 6.9 points ( 1 - 10 sub - range , intermediate level for the eight diseases / conditions investigated ) , and the probability of cognition was 3.1 points ( 1 - 10 sub - range , ranked in the reciprocal third position ) , the total risk awareness was 2.1 points ( 1 - 5 sub - range , all disease / condition risk cognitive level approaches ) ;
At the same time , the results suggested that the public had some positive or good luck , 54.9 % thought that they were less likely to have pulmonary tuberculosis than others . The investigation showed that the external symptoms of pulmonary tuberculosis were 22.6 points ( 0 - 50 sub - range ) , which mainly appeared to be the distance from the patients with pulmonary tuberculosis ;
Internal disease shame is divided into 20.8 points ( range 0 - 50 ) , in which " others will avoid me " , " spouse or male and female friends will not live with me " , " others will look down upon me " and " even if cure is difficult " for the first four ;
Negative emotions ( tension , fear , and fear ) are divided into 3.6 points ( 1 - 5 sub - range ) .
The results showed that the knowledge of pulmonary tuberculosis was positively correlated with the sense of internal disease and severity ( r = 0.11 and 0.13 , r = 0.11 and 0.13 , respectively ) .
( r = 0.14 ) , negative correlation with susceptibility and risk ( r = - 0.21 , - 0.13 ) ;
The sense of internal disease was positively correlated with severity cognition ( r = 0.18 ) .
There was a positive correlation between the two parts ( r = 0.52 ) .
Negative emotions were moderately correlated with the external and internal disgraceful sense ( r ranged from 0.37 to 0.43 ) and positively correlated with severity cognition ( r ranged from 0.12 to 0.16 ) .
Conclusion : The knowledge rate of tuberculosis associated with tuberculosis has reached the requirement of the " Eleventh Five - year Plan " of the Ministry of Health . The risk perception of pulmonary tuberculosis is comparable to the level of chronic disease ( AIDS , myocardial infarction , hypertension , diabetes ) , acute disease or condition ( avian influenza , common cold , food poisoning ) , and there is a bad feeling and negative emotion of pulmonary tuberculosis .
Risk transmission intervention for screening of patients with infectious pulmonary tuberculosis in the second part
Objective : To explore the effective means of screening for patients with pulmonary tuberculosis actively , but it is not paid much attention in our country . This part will discuss the effect of comprehensive intervention in the implementation of risk communication on improving the coordination degree of patients with pulmonary tuberculosis , promoting their close contact with clinical screening and improving the detection of pulmonary tuberculosis cases .
Methods : The patients with infectious pulmonary tuberculosis ( smear positive , Peiyang and smear cavity ) who were aged over 15 years of age in the south mountain area were divided into intervention group and control group ( 285 patients , 135 in the control group and 150 in control group ) .
In the control group , routine screening was carried out according to the National Tuberculosis Control Guidelines , and the physician was instructed not to participate ;
The intervention group used the supervision physician to strengthen the education of education , release screening appointment order , short message reminding and economic incentive comprehensive intervention measures .
Results : 623 patients who had close contacts were identified in the intervention group , and 4.2 in each patient were higher than those expected in the national guide ( P0.001 ) ;
The proportion of patients who had close contact with the risk communication intervention group was 33.7 % ( 55 ) , which was significantly higher than that in the control group ( 9.6 % ( 13 ) ( OR = 3.304 , P = 0.001 ) .
The number of closely contacted subjects per patient was 0.7 and 0.1 for the control group ( IRR = 3.205 , P0.001 ) , respectively . Through clinical examination , 31 cases of pulmonary tuberculosis were found in the intervention group ( 2 of them were confirmed by clinical diagnosis , 29 patients with tuberculosis latent infection ) , and only 7 cases of latent infection were found in the control group ;
For each patient , there was a statistically significant difference between the two groups ( 0.2VS0 . 1 , P0.001 ) . The patient ' s willingness to recommend close contacts was 72.3 % , among which the recommended family screening willingness was the highest ( 91.7 % ) ;
It is expected that work will be lost in close contact screening barriers , and others will be far away from their own and those who lose their economic sources in the top three .
Conclusion : By supervising doctors to strengthen education , issuing screening appointment order , short message reminding and economic incentive , these interventions have promoted the patient ' s recommendation for their close contact to receive screening , improve the identification of close contact persons and the case discovery ;
In order to ensure the patient ' s right to work , balance the patient ' s right to privacy and the right to health of others , how to effectively carry out the screening of the close contact persons of the floating population and the measures to improve the coordination degree of the close contacts are the problems that will be studied in the future .
Transregional referral risk transmission intervention in patients with pulmonary tuberculosis in the third part
Objective : Transregional referral is frequently occurring in the diagnosis of circulating pulmonary tuberculosis patients . It is easy to cause the patient ' s treatment of irregular or even interrupted treatment , which brings great difficulty to the control of pulmonary tuberculosis .
Although the trans - regional referral rate of pulmonary tuberculosis in China is only 3 % , it occupies half of the ideal treatment effect ( death , treatment failure , loss , etc . ) . This part will study the effect of risk transmission measures on improving the coherence and cure rate of treatment of patients with pulmonary tuberculosis .
Methods : In the sub - Saharan mountain area , the patients with pulmonary tuberculosis in floating population were targeted , and the control group was used before and after intervention .
In October 2007 - September 2008 ( prior to intervention ) , the Global Fund ' s approach to managing the management of tuberculosis patients across the region was adopted ;
From October 2008 to September 2009 ( Phase I of the Risk Communication Intervention ) , the implementation of a comprehensive intervention , including " Strengthening health education and patient - patient communication , treatment - time intensive surveillance , cross - regional referral assistance and tracking and strengthening the close link to the ground " , including " in order to enhance patient treatment compliance ;
From October 2009 to September 2011 ( Phase II of Risk Communication Intervention ) , on the basis of the intervention of the intervention of the transfer - to - ground tuberculosis prevention and control agency , the QQ contact platform with the vast majority of the county - city institutions was established . In real time , contact was established with the transfer - in ground ( to remind the other party to follow up the referral tracking of the patient ) , and to communicate with the staff member of the " China disease prevention control system - referral management " ) .
Results : 2244 patients with pulmonary tuberculosis were co - administered in the southern mountain area in 4 years , the total rotation rate was 17.1 % , among which the intervention period was 18.5 % ( 110 ) , 16.1 % ( 179 ) , and 17.5 % ( 94 ) before intervention ( P = 0.439 ) . Before intervention , only 39.4 % of the patients were informed of medical personnel in advance , the intervention period increased to 61.8 % , the second phase reached 86.5 % , and the annual growth rate was 30.0 % ( P0.001 ) .
The rate of referral increased from 51.1 % to 85.5 % in 2011 , with an average annual increase of 18.7 % .
In the past four years , the absolute value of the re - registration decreased by 69 % , and the annual average decrease was 32 . 1 % ;
The rate of cure or completion of treatment was increased from 4.3 % to 59.8 % , but lower than the overall cure rate of the floating population ( 86.0 % ) .
Conclusion : Transregional referral management risk dissemination comprehensive intervention measures - intensive health education and communication between doctors and patients , key supervision of treatment course , referral assistance and communication with the prevention and treatment of foreign tuberculosis , can improve the coherence and therapeutic effect of treatment for patients with tuberculosis of floating population , but can not reduce the occurrence of referral of patients ;
We need to strengthen the care of the floating population and reduce the economic burden on patients with pulmonary tuberculosis .
Innovative :
1 . To quantitatively measure the risk perception of pulmonary tuberculosis and the status quo of illness and shame , and to analyze their correlation ;
2 . The application of risk diffusion method for tuberculosis prevention and treatment of the bottleneck problem _ pulmonary tuberculosis case discovery is not timely , floating population transregional referral _ to intervene , and has a certain breakthrough , such as promoting the implementation of the screening of infectious tuberculosis close contact persons , improving the early detection number of cases and realizing the continuity of treatment of floating population across regions .
【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】:R521
【参考文献】
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