自愿婚前医学检查的影响因素研究：健康信念理论与合理行为理论整合模型的验证

发布时间：2018-02-23 06:19

本文关键词： 婚检医学检查健康信念理论合理行为理论多水平模型 Logistic回归结构方程模型社会赞许性量表　出处：《浙江大学》2012年博士论文　论文类型：学位论文

【摘要】：婚前医学检查是预防和减少出生缺陷和残疾发生的重要措施之一。同时,还具有常见病筛检功能和早发现、早诊断、早治疗的作用。2003年新《婚姻登记条例》将“强制婚检”改为“自愿婚检”后,各地婚检率急剧下滑。本文根据自愿婚检的行为特征和可能的影响因素,筛选和互补国外相关健康行为理论,在整合和互补健康行为理论(HBM)和合理行动理论(TRA)等相关维度的基础上,从理论构造、选择理由等方面提出适合我国婚检依从行为解释和干预的理论假设模型,并提出数个假说,通过多水平多因素Logistic回归模型(MLwiN2.02软件)和结构方程模型(LISREL8.71统计软件)进行实证研究。在明确各维度操作定义的基础上,经过婚姻登记新人定性访谈、建立题项库、专家评价、预试验、信度和效度检验等程序设计调查问卷,采用148个预试样本进行量表条目分析和598个预试样本进行量表信度和效度检验。采用分层随机抽样方法,按照地理分布、经济水平和文化特征等因素选择浙江省有代表性的12个县(市、区)作为调查点,样本量为2572人。采用598个预试样本进行结构方程模型预试验,然后利用2572个扩展样本进行多水平多因素Logistic回归模型和结构方程模型扩展验证。为研究社会赞许性对婚检依从行为影响结构的影响,将2572个扩展样本按社会赞许性量表得分(分割点7/13)分成高、低两组,用结构方程模型进行交叉验证,最终以社会赞许性低组别(n=777)结构方程模型作为本文的研究结果。本文的研究结果主要包括：一是婚检意向和婚检行为的关系。婚检意向人群中75%采纳了婚检行为,有婚检意向而没有去婚检的人群占总数的19.4%,无婚检意向且没有去婚检的人群占总数的2.6%。结构方程模型验证显示,婚检意向对婚检行为的标准化路径系数为0.75(T=22.15,p0.01)。二是行为态度、主观规范、威胁感对婚检意向的作用。行为态度对婚检意向的标化路径系数为0.48(T=8.81,p0.01)；主观规范对婚检意向的直接标化路径系数为0.22(T=4.75,p0.01),间接标化路径系数为0.14,两者合计为0.36；威胁感对婚检意向的标化路径系数为-0.08(T=2.20,p=0.078)。三是婚检益处感、障碍感对婚检行为态度的作用。障碍感对婚检行为态度的标化路径系数为-0.16(T=4.45,p0.01),益处感对婚检行为态度的标化路径系数为0.52(T=11.98,p0.01)。四是益处感与婚检行为的虚假直接因果关系。益处感对婚检行为的没有直接因果关系(标化r=-0.02,p=0.284)。在大样本中(n=2572)益处感对婚检的标化路径系数为-0.16(T=-2.49,p0.01),其虚假联系主要是由社会赞许性高引起的。五是危机感、严重感对威胁感的作用。危机感对威胁感的标化路径系数为0.89(T=37.74,p0.01),严重感对威胁感的标化路径系数为0.52(T=33.59,p0.01)。六是婚检规范信念、遵从动机对婚检主观规范的作用。婚检规范信念对主观规范的标化路径系数为0.64(T=30.59,p0.01),遵从动机对主观规范的标化路径系数为0.46(T=28.08,p0.01)。七是地域因素(主要是环境政策)对婚检行为的作用。多水平多因素Logistic回归模型显示,各变量(含哑变量和截距)的方差成分系数VPC范围为15.40%-17.58%,因此地域环境因素对婚检行为的影响力约占16%。八是年龄、性别、教育水平、职业等作为外部间接变量对婚检行为的影响。多水平多因素Logistic回归模型显示,不同性别、年龄、户籍、教育程度、收入、医疗保险类型、是否曾婚检过等人群间的婚检率差异没有统计学意义。不同职业、近6个月内是否参加过体检、结婚登记类型等人群间的婚检率差异具有显著性。企业职工(国有/非公/私营)、个体工商户、农业劳动者的婚检率比行政事业单位员工要高,OR值分别为1.62(95%CI：1.21～2.18)、2.02(95%CI：1.42～2.88)、3.02(95%CI：1.44～6.34)；近6个月内无医学体检人群婚检率是医学体检人群的1.31倍(95%CI：1.05～1.65)；与初婚未孕人群相比,初婚已孕和再婚人群婚检率是其1.51倍(95%CI：1.14～2.00)和0.35倍(95%CI：0.23～0.51)。本文的主要结论：一是婚检行为主要受行为态度、主观规范、威胁感等通过婚检意向间接影响,其中又以行为态度、主观规范为主；外部政策环境对婚检行为有影响但较小(约占总方差的16%)；个体的性别、年龄、户籍、教育程度、收入、医疗保险类型、是否曾婚检过等人口学变量对婚检没有影响,职业、体检史、结婚登记类型等有影响,结合理论和文献,其影响可能是通过影响行为态度、主观规范、威胁感等维度间接作用于意向或行为。二是社会赞许性会对婚检行为影响因素的网状结构产生影响,特别是益处感和障碍感等婚检行为态度对婚检行为的影响,但社会赞许性对危机感、严重感、规范信念、遵从动机影响较小。结合中国“关系”、“面子”和“跟风”等文化或行为特性,建议在研制中国问卷调查量表时(特别是益处感等),要考虑社会赞许性评价和修正。本文的政策建议(按优先次序)是：一是通过倡导婚检的社会规范和婚检决策影响力人群(如家庭、医生、社区妇女干部等)的作用,强化社区动员,婚检干预往往会取得事半功倍的效果。二是努力消除婚检行为的障碍,如合理布局婚检点和婚检项目,优化婚检流程,保护婚检对象的相关隐私,充分宣传免费婚检的政策,倡导“婚登与婚检一条龙”服务模式,优化各类体检和婚检的合理衔接(如单位体检中增设婚检内容,凭检查结果由政府进行补贴)；提供温馨就诊环境,强化人性化服务、个体化服务并通过“同伴宣传效应”吸引更多婚龄青年婚检。三是从正面引导和宣传婚检的知识和好处。四是对不同的职业、近6个月内是否参加过体检、结婚登记类型(如初婚未孕、初婚已孕和再婚等)等不同人群,采用分类指导、属地化、个性化的干预策略。
[Abstract]:Premarital medical examination is one of the important measures to prevent and reduce birth defects and disability . At the same time , it has the function of screening examination and early detection , early diagnosis and early treatment . On the basis of defining the operation definition of each dimension , through the qualitative interview with the new person of marriage registration , the design questionnaire of the question item bank , expert evaluation , pre - test , reliability and validity test are established , and 148 pre - test sample books are used for the scale entry analysis and 598 pre - test samples to carry out the scale reliability and validity test . A stratified random sampling method was adopted to select 12 counties ( cities and districts ) in Zhejiang province as the survey points , with a sample size of 2572 . The results of this paper mainly include : One is the relationship between the intention of marriage and the behavior of marriage . 75 % of the people who intend to make marriage have adopted the behavior of marriage , there are only 19.4 % of the total number of people without marriage , and 2.6 % of the total number of people who do not go to marriage . The structural equation model shows that the standardized path coefficient of the intention to marriage is 0.75 ( T = 22.15 , p0.01 ) . Secondly , the effect of behavior attitude , subjective norm and threat perception on the intention of marriage inspection . The standard route coefficient of behavior attitude towards marriage inspection intention is 0.48 ( T = 8.81 , p0.01 ) , the direct labeling path coefficient of subjective norm to marriage inspection intention is 0.22 ( T = 4.75 , p0.01 ) , the indirect labeling route coefficient is 0.14 , the total of the two is 0.36 ; the threat perception has a standard route coefficient of - 0.08 ( T = 2.20 , p = 0.078 ) . The third is the sense of the benefits of marriage inspection and the effect of the obstacle on the attitude of the behavior of marriage . The standard path coefficient of the attitude towards marriage inspection is - 0.16 ( T = 4.45 , p0.01 ) , and the coefficient of benefit to the attitude towards marriage is 0.52 ( T = 11.98 , p0.01 ) . Fourth , there is no direct causal relationship between the sense of benefit and the behavior of marriage . There is no direct causal relationship between the sense of benefit and the behavior of the marriage ( r = - 0.02 , p = 0.284 ) . Among the large samples ( n = 2572 ) , the standard path coefficient of marriage inspection was - 0.16 ( T = - 2.49 , p0.01 ) , and its false connection was mainly caused by social approval . 5 is a sense of necessity and a serious sense of threat . The critical path coefficient for threat perception is 0.89 ( T = 37.74 , p0.01 ) , and the critical path coefficient to the threat perception is 0.52 ( T = 33.59 , p0.01 ) . VI is the code of marriage inspection and the effect of motivation on subjective norm of marriage inspection . The standard belief of marriage inspection is 0.64 ( T = 30.59 , p0.01 ) , and the standard path coefficient of motivation to subjective norm is 0.46 ( T = 28.08 , p0.01 ) . The multi - level multi - factor logistic regression model shows that the variance component coefficient VPC range of each variable ( including dummy variable and intercept ) ranges from 15.40 % to 17.58 % , so the influence of regional environmental factors on the behavior of marriage is about 16 % . There was no significant difference in the rate of marriage between the two groups , such as age , sex , educational level , occupation and so on . The multiple factors Logistic regression model showed that there was no significant difference in the rate of marriage between the groups of different sex , age , household , educational level , income , medical insurance type , and whether there had been a marriage . The odds ratio of marriage and examination between the workers ( state - owned / non - public / private ) , individual and commercial households and agricultural labourers was 1.62 ( 95 % CI : 1.21 - 2.18 ) , 3.02 ( 95 % CI : 1.42 - 2.88 ) , 3.02 ( 95 % CI : 1.44 - 6.34 ) . The main conclusions are as follows : First , the behavior attitude , subjective norm , threat perception , etc . are mainly influenced by the intention of marriage inspection , in which the behavior attitude and subjective norm are the main factors ; the external policy environment has an influence on the behavior of marriage , but less ( about 16 % of the total variance ) ; the influence of the sex , age , household , educational level , income , medical insurance type and the type of marriage registration have no influence on the marriage inspection . Second , the social approbation will influence the net structure of the influencing factors of marriage inspection behavior , especially the influence of the attitude of marriage inspection behavior such as the sense of benefit and obstacle feeling on the behavior of marriage , but the social approbation has little influence on the crisis sense , the serious feeling , the normative belief and the motivation . The policy recommendations of this article ( in order of priority ) are : First , through advocacy of the role of social norms and decision - making influence groups ( such as family , doctor , community women ' s cadres , etc . ) , the community mobilization is strengthened , and the intervention of marriage inspection often results in half - effort . Second , efforts are made to eliminate obstacles to marriage inspection , such as reasonable layout of marriage inspection points and marriage inspection items , optimization of marriage inspection process , protection of relevant privacy of marriage inspection objects , full publicity of the policy of free marriage inspection , promotion of " marriage registration and marriage inspection one - stop " service mode , optimizing various medical examination and marriage inspection one - stop service mode , optimizing various medical examination and marriage inspection , providing warm and visiting environment , strengthening humanized service , personalized service and attracting more young people for marriage through " peer publicity effect " . The third is to guide and promote the knowledge and benefits of marriage inspection from the front . Four are different groups , such as physical examination in the last six months , the type of marriage registration ( such as early marriage , pregnancy and remarriage , etc . ) .

【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2012
【分类号】：R169.1

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