我国三城市流产后计划生育服务的影响因素分析及服务质量的综合评价

发布时间：2018-03-02 21:50

本文选题：流产后计划生育服务　切入点：影响因素探索　出处：《北京协和医学院》2013年博士论文　论文类型：学位论文

【摘要】：[研究目的] 一、总目的对我国三城市流产后计划生育服务质量的影响因素进行探索(简称“影响因素探索”),并对三城市的流产后计划生育服务质量进行综合评价(简称“质量综合评价”),为优质的流产后计划生育服务的进一步开展提供参考。二、具体目的 (一)利用重复流产率、避孕措施落实、性与生殖健康知识水平及服务满意度四大类国际上常用的流产项目评估指标的影响因素分析结果,结合构建的妇女流产后避孕行为影响因素的验证性因子分析SEM,从流产后计划生育服务质量提高的目的(防止非意愿妊娠的发生,降低流产率和重复流产率)出发,探索影响流产后计划生育服务质量的因素,并提出相应的对策。 (二)在WHO优质流产后计划生育服务框架的基础上,利用综合评分法、蛛网图模型法和聚类分析法对北京、上海、郑州三地区的29家医院的流产后计划生育服务质量进行综合评价,探索性地综合评估我国流产后计划生育服务质量的优势和不足,并验证几种综合评价方法在流产后计划生育服务质量评估方面的适用性,为流产后计划生育服务质量的评估提供参考。 [研究方法] 一、资料来源本研究是在欧盟FP6中国流产后计划生育服务研究数据基础上的再分析、再挖掘。数据基本情况如下采用分层随机化的方法,在北京、上海、郑州三个城市选择了29家医院。在这29家医院中,共调查流产妇女3132人。流产妇女的纳入标准为：①到选定的医院寻求流产服务；②年龄25岁；③早期妊娠；④能在半年后随访,随访方式可以为反诊或是电话随访；⑤愿意参加本调查。排除标准为：不愿参加本研究者或不能坚持随访者。二、研究方法在服务质量影响因素探索方面,本文综合运用了传统经典的统计方法及现代统计学方法。使用的经典统计分析方法主要包括描述性分析、χ2检验、Logistic回归及多元线性回归等。使用的现代统计学方法是新一代统计学三大进展中的最突出代表：SEM。在服务质量综合评价方面,主要在WHO的优质流产后计划生育服务框架的基础上,探索性的采用了综合评价法中的综合评分法、蛛网图评价法和聚类分析法,对服务质量进行了综合评估。在本研究数据的统计分析及综合评价中,主要采用SPSS17.0软悠扬；在SEM构建的过程中,首先采用SPSS17.0软件对数据进行插补,在数据插补完成后采用AMOS软件进行SEM的构建；在综合评价中的蛛网图评价法中,采用了Microsoft Office软件进行了模型图的构建。 [研究结果] 一、影响因素探索部分 (一)国际上常用的四大类流产项目评估指标的影响因素分析 1.重复流产 (1)流产妇女的妊娠原因未避孕(64.0%)和避孕失败(36.0%)是本次调查中3132名流产妇女的主要妊娠原因。妇女不避孕的主要原因是“在没有准备好避孕药具的情况下进行了同房”(43.3%)和“因为知道但不想使用避孕方法”(34.6%)。绝大多数避孕失败的发生是在使用短效的现代避孕措施(避孕套39.2%、紧急避孕药20.1%、口服避孕药12.4%)中和传统的避孕措施(安全期29.7%,体外射精20.1%)中,在使用长效避孕措施(宫内节育器1.5%)中发生避孕失败的较少。 (2)重复流产的影响因素多因素Logistic回归分析发现,知识得分和性生活时间与重复流产的发生有关,与知识得分60分的妇女相比,知识得分≥60分的妇女重复流产的发生相对较少(OR95%CI：0.694(0.498-0.969)；在性生活时间方面,与性生活时间1年的相比,性生活时间≥1年的妇女发生重复流产的可能越大(OR95%CI：29.44(15.327-56.548))。 2.性与生殖健康知识多因素Logistic回归分析发现,年龄和出生地是性与生殖健康知识水平的影响因素,与年龄22岁的妇女相比,年龄≥22的妇女,在性与生殖健康知识方面及格率越高(OR95%CI:1.625(1.164-2.270));与出生在农村的妇女相比,出生在城镇(OR95%CI：1.800(1.241-2.611))和城市(OR95%CI：1.554(1.102-2.190))的妇女性与生殖健康知识方面及格率越高。 3.避孕措施 (1)流产妇女避孕措施的使用情况流产前和流产后,妇女使用的主要的避学措施均为避孕套(前：77.5%,后：78.2%)和体外射精(前：11.6%,后：7.7%)。 (2)流产妇女避孕药具选择时各因素的考虑情况在避孕药具的选择时,妇女最关注的为避孕措施的安全性(74.6%)和有效性(70.0%),最不关注的为避孕药具的价格(10.5%)。 (3)流产后首次性生活避孕措施落实的影响因素多因素Logistic回归分析发现,婚姻状况、男方是否关心避孕问题、男女年龄差距和性生活时间与流产后首次性生活时避孕措施的落实情况相关。与男方不关心避孕问题的相比,男方关系避孕问题的妇女流产后首次性生活时避孕措施的落实率高(OR95%CI：1.413(1.102-1.812))；与性生活时间1年的相比,性生活时间≥1年的妇女流产后首次性生活时避孕措施的落实率高(OR95%CI：1.382(1.076-1.774))；与已婚的妇女相比,未婚的妇女流产后首次性生活时避孕措施的落实率低(OR95%CI：0.66(0.498-0.875))；与男女年龄差距2岁的相比,男女年龄差距≥2的妇女流产后首次性生活时避孕措施的落实率低(OR95%CI：0.749(0.593-0.946))。 (4)各类避孕措施使用的影响因素影响避孕套、口服避孕药、IUD、紧急避孕药、传统/现代避孕措施、短效/长效避孕措施使用的多因素Logistic回归分析结果见汇总表ST-I。 (二)妇女流产后避孕行为影响因素的验证性因子分析SEM构建结果采用AMOS17.0拟合的SEM结果见图SF-1,图中所有的路径系数均为标准化后的路径系数。模型的拟合结果显示χ2=841.782(P0.05),GFI=0.969, AGFI=0.949, PGFI=0.596,尽管P值小于0.05,但由本研究拟合的GFI、AGFI和PGFI非常理想,所以认为模型对数据的拟合程度较高。SEM分析结果显示,性与生殖健康知识、个体因素、社会经济地位、社会支持等潜变量均会通过直接和/或间接的途径来影响妇女流产后的避孕行为。注： 1.为简洁明了,本表只汇总了多因素分析有意义的变量： 2.口服避孕药单因素分析没有P0.05的变量,因此不进行多因素分析,故在本表中未纳入口服避孕药的结果； 3.自变量赋值：年龄：1=22岁(ref),2=≥22岁；男性年龄分组：1=24岁(ref),2=≥24岁；性生活时间：1=1年(ref)2=≥1年；其余自变量:0=否(ref),1=是 4.因变量赋值避孕套(0=不使用；1=使用)；宫内节育器(0=不使用；1=使用)；紧急避孕药(0=不使用；1=使用)；传统/现代避孕措施(0=传统；1=现代)；短效/长效避孕措施(0=短效：1=长效)。二、质量综合评价部分综合评分法结果显示,我国三城市的流产后计划生育服务质量在人际关系(82.17分)和服务的连续性(82.66分)方面相对较好,在服务时机(57.67分)、避孕方法的选择(62.85分)、技术力量(57.26分)方面的能力次之,在宣教和咨询方面的能力最弱(48.46分)：上海、北京、郑州三地区的综合得分分别为72.33、61.84和57.32分。蛛网图评价法结果显示,三城市的服务质量在WHO优质流产后计划生育服务框架的六个方面有很好的一致性。聚类分析结果显示,纳入研究的29家医院的流产后计划生育服务质量总体可分高、中、低三类,各类中的医院数目分别为9、12和8家。 [研究结论] 一、影响因素探讨部分探讨流产后计划生育服务质量的影响因素,提高流产后计划生育服务质量的目的是降低流产及重复流产的发生率。非意愿妊娠是流产和重复流产发生的根源,要解决流产和重复流产问题,需要从非意愿妊娠发生的主要原因来入手。因此,提高流产后计划生育服务的质量,解决流产和重复流产问题,主要需从优化避孕药具提供网络、改变妇女“不想使用避孕方法”的态度和解决避孕失败问题三大方面来进行。提高年轻化、未育化的流产人群的避孕药可及性,是避孕药具网络优化的一大切入点；改变流产妇女“不想使用避孕方法”的态度,不仅需要提高流产妇女的性与生殖健康知识水平,还需要改善外界环境的影响,如增加男方在避孕节育和流产服务中的参与等；要解决“避孕失败”问题,需要通过宣教、咨询等各种措施,来提高流产妇女的避孕相关知识水平和避孕技能,来减少安全期和体外射精等传统避孕方法的使用,提高各类短效现代避孕措施的正确使用率和坚持使用率,增加长效现代避孕措施的使用率。妇女流产后避孕行为影响因素的SEM构建结果显示,妇女流产后避孕行为的改变,受到多种因素共同作用的影响。因此,要改变妇女流产后的避孕行为,不能仅仅依靠一种因素的改变。而是要协调采用多种措施,综合提高流产后的计划生育服务质量,以达到预防非意愿妊娠发生,进而达到降低流产率和重复流产率的目的。二、质量综合评价部分从WHO的优质流产后计划生育服务框架的六方面来看,我国三城市的流产后计划生育服务质量在人际关系和服务的连续性方面相对较好,在服务时机、避孕方法的选择、技术力量方面的能力次之,在宣教和咨询方面的能力最弱。三城市的服务质量在WHO优质流产后计划生育服务框架的六方面有很好的一致性。综合评分法和聚类分析法两种评估结果的一致性,不仅验证了本研究中质量综合评价结果的可靠性和稳定性,同时说明了两种方法在医院流产后计划生育服务质量的综合评价上是适用的。
[Abstract]:[research purposes]
First, the general purpose
The influence factors of family planning service quality three city in China to explore the post abortion (referred to as "exploring the influencing factors"), and a comprehensive evaluation of the quality of family planning services three city after abortion (referred to as the "comprehensive evaluation" quality), to provide the reference for further development of family planning service quality after abortion.
Two, specific purpose
(a) the repeated abortion rate, contraceptive measures implemented, factors affecting the satisfaction of sexual and reproductive health knowledge and service level of four major categories of international common abortion project evaluation index analysis results, combined with the construction of the women after abortion contraceptive behavior affects the confirmatory factor analysis of factors of SEM, from the post abortion family planning service quality improvement (to prevent unintended pregnancy, reduce the abortion rate and repeated abortion rate) of family planning service quality factors and explore the effects of post abortion, and put forward the corresponding countermeasures.
(two) the foundation of family planning services in the framework of the WHO quality after abortion, using the comprehensive evaluation method, spidergram model method and cluster analysis method in Beijing, Shanghai, Zhengzhou 29 hospitals in three areas of post abortion family planning service quality comprehensive evaluation, explore the family planning service quality comprehensive evaluation of China's abortion the advantages and disadvantages, and verify the applicability of several evaluation methods of family planning service quality in terms of the evaluation of post abortion family planning service, to provide reference for quality evaluation after abortion.
[research methods]
First, source of information
This study is based on the data of the research data of family planning service after abortion in FP6 China. The basic data are as follows
Methods the stratified randomization in Beijing, Shanghai, Zhengzhou three city chose 29 hospitals. In these 29 hospitals, investigated a total of 3132 people. Abortion abortion included: 1 to the selected hospital for abortion services; the age of 25 years; early pregnancy; the follow-up in after half a year follow-up for diagnosis or anti telephone follow-up; the willingness to participate in this investigation. The exclusion criteria were unwilling to participate in the research or not followed up.
Two, research methods
In the exploration of the factors affecting the quality of service, this paper uses statistical methods of classical and modern statistical methods. Classical statistical analysis methods used include descriptive analysis, 2 test, Logistic regression and multiple linear regression. The use of modern statistical method is the most prominent representative of a new generation was in progress: three SEM.
On the basis of WHO's quality abortion family planning service framework, the comprehensive evaluation method of comprehensive evaluation, spider web diagram and cluster analysis were adopted to comprehensively evaluate service quality.
In the comprehensive evaluation and statistical analysis of the research data, mainly using SPSS17.0 soft in the process of construction of SEM melodious; first of all, using SPSS17.0 software for data interpolation, based on data interpolation is completed using AMOS software SEM; spider diagram evaluation method in comprehensive evaluation, using the Microsoft Office software the construction of model.
[results]
First, the exploration part of the influencing factors
(1) analysis of factors influencing the evaluation indexes of four major types of abortion items commonly used in the world
1. repeated abortion
(1) the causes of pregnant women's pregnancy
(64%) no contraception and contraceptive failure (36%) is the main cause of pregnancy in this investigation 3132 abortion women. The main reason is the "women's contraception were not ready for contraceptive intercourse in the case" (43.3%) and "because you know but do not want to use contraceptive method" (34.6%) the vast majority of contraceptive failure occurred. In the use of short acting contraceptives (condoms 39.2%, modern 20.1% emergency contraceptives, oral contraceptives 12.4%) and traditional contraceptive measures (safety period of 29.7%, 20.1%, in vitro ejaculation) using long-acting contraceptive measures (IUD 1.5%) in the occurrence of contraceptive failure is less.
(2) the influencing factors of repeated abortion
Multivariate Logistic regression analysis showed that the score of knowledge and life time and repeated abortion rate, compared with the knowledge score of 60 women, relatively less knowledge score of equal or greater than 60 points repeated abortion women (OR95%CI:0.694 (0.498-0.969); in the life of the time, compared with the life time of 1 years, of the life time is more than 1 years of repeated abortion women more likely (OR95%CI:29.44 (15.327-56.548)).
2. sex and reproductive health knowledge
Multivariate Logistic regression analysis showed that age and birth are factors affecting sexual and reproductive health knowledge level, compared with women aged 22 or older, 22 of women in sexual and reproductive health knowledge in the higher rate (OR95%CI:1.625 (1.164-2.270)); compared with the students in rural women born in the town of (OR95%CI:1.800 (1.241-2.611)) and city (OR95%CI:1.554 (1.102-2.190)) of the women's sexual and reproductive health knowledge of the passing rate is higher.
3. contraceptive measures
(1) the use of contraceptive measures for women with abortion
Before and after abortion, the main avoidance measures used by women were condoms (before: 77.5%, post: 78.2%) and ejaculatory (before: 11.6%, after 7.7%).
(2) the factors considered when choosing contraceptive abortion women
In the choice of contraceptives, safety for contraception in women are most concerned about (74.6%) and effectiveness (70%), the most concern is the price of contraceptives (10.5%).
(3) factors affecting the implementation of first sexual contraception after abortion
Multivariate Logistic regression analysis showed that marital status, whether the man cares about contraception, related to the implementation of the age gap between the men and women and sexual life time after abortion and contraception for the first time sexual life. Compared with the man don't care about contraception, male contraception of women after abortion relationship for the first time sexual life high rate of contraceptive measures (OR95%CI:1.413 (1.102-1.812)); compared with the life time of 1 years, life time more than 1 years of women after abortion for the first time sexual life contraceptive measures high rate (OR95%CI:1.382 (1.076-1.774)); compared with married women, unmarried women after abortion for the first time sexual life and low rate of contraceptive measures (OR95%CI:0.66 (0.498-0.875)); and the men and women age gap of 2 years compared to men and women age gap of more than 2 women after abortion for the first time sexual life contraceptive measures (low rate of OR95%CI:0. 749 (0.593-0.946)).
(4) factors affecting the use of various contraceptive measures
The effects of condoms, oral contraceptives, IUD, emergency contraceptives, traditional / modern contraceptive measures, short acting / long acting contraceptive measures were analyzed by multivariate Logistic regression analysis. The total table ST-I.
(two) a confirmatory factor analysis of factors influencing contraception after abortion in women SEM construction results
Using AMOS17.0 fitting SEM results shown in figure SF-1, in which all path coefficients are standardized path coefficients. The results of the model fitting showed that x 2=841.782 (P0.05), GFI=0.969, AGFI=0.949, PGFI=0.596, while the P value is less than 0.05, but by the fitting of GFI, AGFI and PGFI is very ideal, so that the model the data of high fitting degree.SEM analysis showed that the sexual and reproductive health knowledge, individual factors, social economic status, social support and other latent variables will influence the contraceptive behavior of women after abortion by way of direct and / or indirect.
Note:
1. for succinct, this table only sums up the variables that are meaningful in multiple factors analysis.
2. the single factor analysis of oral contraceptives did not have P0.05 variables, so no multi factor analysis was carried out, so the results of oral contraceptives were not included in this table.
3. variable assignment: age: 1=22 (Ref), 2= more than 22 years old; male age groups: 1=24 years (Ref), 2= = 24; life time: 1=1 (Ref) 2= more than 1 years; other variables: 0= (Ref), 1=
4. variables were assigned as condoms (0= not used; 1= used); intrauterine devices (0= not used; 1= used); emergency contraceptives (0= not used; 1= used); traditional / modern contraceptive measures (0= tradition; 1= modern); short acting / long acting contraceptive measures (0=: short effect: 1= long effect).
Two, the quality comprehensive evaluation part
Comprehensive evaluation results showed that the quality of family planning services in the interpersonal relationship three city of our country after abortion (82.17 points) and continuity of service (82.66) is relatively better, in the service time (57.67 points), the choice of contraception (62.85 points), technology (57.26) the ability of time the education and counseling in the ability of the weakest (48.46 points): Shanghai, Beijing, Zhengzhou three area comprehensive scores were 72.33,61.84 and 57.32.
The results of arachnographic evaluation showed that the quality of service in the three cities was in good agreement with the six aspects of the family planning service framework after WHO high quality abortion.
The results of cluster analysis showed that the quality of post abortion family planning service in 29 hospitals was generally high, with a low level of three, and the number of hospitals in various hospitals was 9,12 and 8, respectively.
[Conclusion]
First, the discussion of influencing factors
Factors affecting the quality of post abortion family planning service, family planning services to improve the quality of abortion is to reduce the incidence of abortion and repeated abortion. Unwanted pregnancy is the root of abortion and repeated abortion occurred, to solve the problem of abortion and repeated abortion, need the main reasons from the unwanted pregnancy happened to start. Therefore, to improve the quality of family planning services after abortion, abortion and repeated abortion to solve the problem, mainly from the need to provide network optimization of contraceptives, "do not want to change the attitude of women to use contraception" and solve the problems of three aspects of contraceptive failure.
Improve young, no children of contraceptives and abortion groups, is a big breakthrough point of contraceptive network optimization; change of abortion women "do not want to use contraception" attitude, not only need to improve sexual and reproductive health knowledge of abortion women, also needs to improve the external environment, such as increasing the man participate in contraception and abortion in the service; to solve the "contraceptive failure" problem, through education, counseling and other measures to improve the abortion contraceptive knowledge and contraceptive skills, to reduce the use of safety and in vitro ejaculation and other traditional contraceptive methods, improve the correct use of all kinds of modern short acting contraceptive measures the rate and insist on using rate, increased use of long-acting modern contraception rate.
Women after abortion contraceptive behavior influencing factors SEM construction results show that the contraceptive behavior changes after abortion, affected by many factors. Therefore, to change the contraceptive behavior of women after abortion, not only depends on a factor change. But to coordinate with a variety of measures to improve the comprehensive post abortion family planning the quality of service, in order to prevent unwanted pregnancy, so as to reduce the abortion rate and repeated abortion rate.
Two, the quality comprehensive evaluation part
From the six aspects: WHO quality PAFPS framework, three city China post abortion family planning service quality in the continuity of the interpersonal relationship and the service is relatively good, in the service time, the choice of contraception, the ability of technical force, in education and consulting the weakest. There is a good agreement between the six three city service quality of family planning services in the framework of the WHO quality after abortion.
The consistency between the two evaluation methods is not only verified the reliability and stability of the quality comprehensive evaluation results, but also shows that the two methods are applicable to the comprehensive evaluation of family planning service quality after abortion in hospital.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R169.4

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