本文選題：結(jié)核病 + 依從性�。� 參考：《華中科技大學(xué)》2013年博士論文

【摘要】：研究目的 本研究主要針對(duì)目前結(jié)核病患者遵醫(yī)行為測(cè)量的研究空白，通過(guò)現(xiàn)場(chǎng)調(diào)查對(duì)影響結(jié)核病患者遵醫(yī)行為的一系列因素進(jìn)行篩選、驗(yàn)證，最終建立準(zhǔn)確、有效的結(jié)核病患者遵醫(yī)行為評(píng)定量表。 研究方法 本研究首先通過(guò)查閱文獻(xiàn)和小組訪談了解結(jié)核病患者遵醫(yī)行為研究現(xiàn)狀和可能的影響因素，在此基礎(chǔ)上設(shè)計(jì)調(diào)查問卷初稿。課題組通過(guò)預(yù)調(diào)查對(duì)問卷進(jìn)一步小幅度修改后于2010年9月至2011年8月期間在武漢市江漢區(qū)和xZ口區(qū)23家社區(qū)衛(wèi)生服務(wù)中心對(duì)所有確診在管的結(jié)核病患者進(jìn)行一對(duì)一現(xiàn)場(chǎng)調(diào)查。社區(qū)衛(wèi)生服務(wù)中心結(jié)核病防治工作人員對(duì)患者進(jìn)行現(xiàn)場(chǎng)調(diào)查后，對(duì)患者的取藥記錄進(jìn)行隨訪登記，根據(jù)取藥記錄計(jì)算患者藥物空白時(shí)間比例（continuous multiple-interval medication gaps, CMG）定量判斷患者遵醫(yī)行為的好壞。調(diào)查數(shù)據(jù)收集整理后，應(yīng)用均數(shù)、標(biāo)準(zhǔn)差、中位數(shù)、構(gòu)成比等對(duì)患者基本特征和可能的依從性影響因素進(jìn)行描述性分析，應(yīng)用多因素Logistic回歸分析在控制其它因素的情況下，確定患者依從性的影響因素。研究主要應(yīng)用分辨力系數(shù)、相關(guān)分析以及探索性因子分析對(duì)量表?xiàng)l目進(jìn)行篩選。量表信度主要應(yīng)用克朗巴赫系數(shù)、分半信度及重測(cè)信度進(jìn)行評(píng)價(jià)。量表效度主要應(yīng)用內(nèi)容效度、結(jié)構(gòu)效度、聚斂效度和標(biāo)準(zhǔn)關(guān)聯(lián)效度進(jìn)行評(píng)價(jià)。應(yīng)用ROC曲線分析對(duì)量表的預(yù)測(cè)價(jià)值進(jìn)行評(píng)價(jià)并確定量表的診斷界值，在此基礎(chǔ)上對(duì)量表和CMG的診斷結(jié)果做一致性分析，計(jì)算量表靈敏度、特異度、陽(yáng)性預(yù)測(cè)值和陰性預(yù)測(cè)值。最后采用多因素Logistic回歸分析和路徑分析研究量表各維度與遵醫(yī)行為之間的關(guān)系。 以上所有分析均在使用EpiData3.0軟件進(jìn)行數(shù)據(jù)雙錄入后，使用Amos20.0進(jìn)行證實(shí)性因子分析和路徑分析，應(yīng)用SAS9.2軟件進(jìn)行其它統(tǒng)計(jì)分析。在數(shù)據(jù)分析過(guò)程中，對(duì)調(diào)查表中的缺失值以相應(yīng)條目的中位數(shù)值替換。 結(jié)果 1、結(jié)核病患者遵醫(yī)行為現(xiàn)狀與影響因素分析。研究中共調(diào)查438名結(jié)核病患者，平均年齡為39歲，男性占68.04%。根據(jù)CMG判斷標(biāo)準(zhǔn)，調(diào)查對(duì)象中有不遵醫(yī)行為的人數(shù)為181，不遵醫(yī)行為發(fā)生率為41.32%。多因素分析顯示患者年齡、文化程度和婚姻狀況與其遵醫(yī)行為沒有明顯相關(guān)性。相對(duì)于年齡小于20歲的患者，年齡在40~60歲之間的患者更傾向于不遵醫(yī)，OR值為0.25（95%CI：0.09~0.71）。衛(wèi)生服務(wù)可及性、醫(yī)患交流、患者行為特點(diǎn)、患者心理特點(diǎn)、患者對(duì)疾病態(tài)度以及社會(huì)支持與患者遵醫(yī)行為有顯著相關(guān)性。 2、結(jié)核病患者遵醫(yī)行為評(píng)定量表的研制。量表包含有九個(gè)維度30個(gè)條目，九個(gè)維度分別為醫(yī)患交流、行為特點(diǎn)、治療信心、社會(huì)支持、心理狀況、生活習(xí)慣、應(yīng)對(duì)方式、記憶力以及衛(wèi)生服務(wù)可及性。量表的克朗巴赫系數(shù)、重測(cè)信度和分半信度分別為0.87、0.83和0.85。量表9個(gè)維度的信度分別為0.88、0.78、0.73、0.75、0.67、0.78、0.77、0.51和0.52。Pearson相關(guān)分析顯示量表總分與每個(gè)維度的得分有顯著性相關(guān)（P0.001）提示TBMAS有較好的內(nèi)容效度。量表總分及每個(gè)維度得分與患者取服藥記錄有顯著性相關(guān)顯示其具有好的聚斂效度和標(biāo)準(zhǔn)關(guān)聯(lián)效度。量表30個(gè)條目證實(shí)性因子分析后的因子載荷都大于0.4，結(jié)構(gòu)方程模型擬合評(píng)價(jià)指標(biāo)GIF、CFI及RMR值等顯示模型擬合良好，綜合說(shuō)明了量表的結(jié)構(gòu)效度較好。ROC曲線分析顯示曲線下面積為0.82（95%CI：0.77-0.86），量表總分取113為界值點(diǎn)時(shí)，量表靈敏度和特異度分別為82.9%和69.3%，陽(yáng)性預(yù)測(cè)值和陰性預(yù)測(cè)值分別為65.5%和85.2%。 3、結(jié)核病患者遵醫(yī)行為評(píng)定量表各維度與遵醫(yī)行為關(guān)系研究。多因素Logistic回歸分析顯示患者在量表九個(gè)維度得分大于相應(yīng)界值時(shí)，量表九個(gè)維度所反映的影響因素對(duì)促進(jìn)患者遵醫(yī)行為有保護(hù)作用，反之則為危險(xiǎn)因素。路徑分析顯示治療信心、心理特點(diǎn)和生活習(xí)慣對(duì)患者遵醫(yī)行為只有直接影響，其標(biāo)準(zhǔn)化影響效應(yīng)分別為0.36、0.16和0.11。醫(yī)患交流、社會(huì)支持對(duì)患者遵醫(yī)行為既有直接影響也有間接影響，總的影響效應(yīng)為0.30和0.27。行為特點(diǎn)、應(yīng)對(duì)方式、記憶力和衛(wèi)生服務(wù)可及性對(duì)遵醫(yī)行為的影響主要為間接影響，影響效應(yīng)分別為0.19、0.18、0.14和0.09。 結(jié)論和建議 結(jié)核病患者服藥依從性較差。結(jié)核病患者遵醫(yī)行為評(píng)定量表具有可靠的信度和效度，可以被結(jié)核病防治工作者用作判斷患者依從性的一個(gè)有效工具。結(jié)核病患者年齡和婚姻狀況與遵醫(yī)行為沒有明顯相關(guān)，患者文化程度在單因素分析時(shí)與遵醫(yī)行為呈正相關(guān)，40~60歲年齡段患者比其他年齡段患者不遵醫(yī)的危險(xiǎn)性增加。患者治療信心對(duì)遵醫(yī)行為影響最大，其次為醫(yī)患交流和社會(huì)支持，其它因素主要通過(guò)這三個(gè)因素對(duì)遵醫(yī)行為產(chǎn)生影響。 有必要在其他地區(qū)對(duì)結(jié)核病患者遵醫(yī)行為評(píng)定量表的信度、效度及使用價(jià)值開展進(jìn)一步實(shí)踐研究。在DOTS策略實(shí)施的過(guò)程中需要重視患者實(shí)際服藥的依從性，可以考慮根據(jù)患者的遵醫(yī)行為對(duì)其實(shí)施科學(xué)的分類管理。醫(yī)務(wù)人員應(yīng)該加強(qiáng)與患者的交流，提高患者治療結(jié)核病的信心。 創(chuàng)新和局限性 首先，本研究緊密跟蹤結(jié)核病防治這一熱點(diǎn)研究領(lǐng)域，但并不是重復(fù)國(guó)內(nèi)外其他學(xué)者的研究工作，而是從國(guó)際該領(lǐng)域前沿出發(fā)，從研究結(jié)核病患者的遵醫(yī)行為入手，，對(duì)DOTS策略的技術(shù)要素DOT提出改進(jìn)的科學(xué)依據(jù)，并建立實(shí)用行強(qiáng)的測(cè)量工具，有可能對(duì)DOTS策略的深化和改良起到實(shí)質(zhì)性的促進(jìn)作用。另外，本研究成功研制了第一份專門針對(duì)結(jié)核病患者遵醫(yī)行為的評(píng)定量表，該量表在發(fā)現(xiàn)不遵醫(yī)患者的同時(shí)還能篩選出影響該患者不遵醫(yī)的危險(xiǎn)因素，是一項(xiàng)極具開拓性的嘗試。從衛(wèi)生管理學(xué)的角度分析，本研究是管理策略研究從衛(wèi)生政策研究向疾病防治實(shí)踐研究的深化，是一種開拓性探索。 本研究的局限性主要體現(xiàn)在兩個(gè)方面。首先，結(jié)核病患者遵醫(yī)行為評(píng)定量表設(shè)計(jì)研制時(shí)的調(diào)查人群都為武漢市城區(qū)結(jié)核病患者，尚需在更多地區(qū)尤其是農(nóng)村地區(qū)實(shí)踐后進(jìn)一步驗(yàn)證其科學(xué)性和實(shí)用性。另外，研究中采用CMG值作為判斷患者依從性好壞的主要標(biāo)準(zhǔn)，雖然CMG值是一個(gè)客觀的綜合測(cè)量患者服藥情況的指標(biāo)并被學(xué)術(shù)界所認(rèn)可和廣泛使用，但是該指標(biāo)不能判斷患者拿藥之后是否按時(shí)按量服用，因此有必要采用更加客觀準(zhǔn)確的方法研究結(jié)核病患者遵醫(yī)行為，并對(duì)量表效度進(jìn)行評(píng)價(jià)。
[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.

【學(xué)位授予單位】：華中科技大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2013
【分類號(hào)】：R52

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