本文選題：肺結(jié)核　切入點：風(fēng)險傳播　出處：《華中科技大學(xué)》2013年博士論文

【摘要】：我國是全球22個結(jié)核病流行嚴重的國家之一，結(jié)核病負擔(dān)全球第二。流動人口肺結(jié)核是當(dāng)前中國結(jié)核病控制的一大難題，病例發(fā)現(xiàn)不及時、肺結(jié)核患者跨區(qū)域流動是肺結(jié)核高治愈率背景下提高結(jié)核病控制質(zhì)量的瓶頸。 風(fēng)險傳播，是個體、群體以及機構(gòu)之間交換有關(guān)風(fēng)險的信息、意見和看法的互動過程。風(fēng)險傳播應(yīng)用于臨床醫(yī)療領(lǐng)域，主要是醫(yī)患之間分享和討論有關(guān)醫(yī)療服務(wù)或健康行為利弊的信息，在個體化風(fēng)險信息的基礎(chǔ)上進行溝通，幫助患者選擇某項醫(yī)療服務(wù)或改變不良行為。 本文在深圳市南山區(qū)采用風(fēng)險傳播，在雙向溝通、患者充分知情、提醒及激勵的前提下，調(diào)動肺結(jié)核患者的自主能動性，促進肺結(jié)核病例的發(fā)現(xiàn)、實現(xiàn)跨區(qū)域轉(zhuǎn)診患者治療的延續(xù)性，嘗試肺結(jié)核控制領(lǐng)域新難題的突破。 第一部分普通人群肺結(jié)核風(fēng)險認知和病恥感 目的：風(fēng)險認知是指人們對風(fēng)險性質(zhì)和嚴重程度的主觀判斷，是采取健康行為或改變不良行為習(xí)慣的重要動力；肺結(jié)核病恥感指因患肺結(jié)核經(jīng)歷過或者預(yù)期受到負面對待，而產(chǎn)生的被排斥、拒絕、責(zé)難、貶低以及羞恥、有罪的個體體驗，也是一種社會現(xiàn)象，是患者延遲就診和治療不依從的重要影響因素。本部分將掌握居民對肺結(jié)核的風(fēng)險認知和病恥感現(xiàn)狀，為肺結(jié)核患者相關(guān)健康行為（接觸者篩查、就診、治療等）干預(yù)提供基礎(chǔ)。 方法：通過分層抽樣方法，對在社區(qū)健康服務(wù)中心就診的492名非肺結(jié)核患者進行問卷調(diào)查。 結(jié)果：調(diào)查對象肺結(jié)核相關(guān)知識知曉率為82.0%；肺結(jié)核嚴重性認知6.9分（1-10分范圍，為調(diào)查的八種疾病/狀況的中間水平）、可能性認知為3.1分（1-10分范圍，排在倒數(shù)第三位），總風(fēng)險認知為2.1分（1-5分范圍，所有疾病/狀況風(fēng)險認知水平接近）；同時結(jié)果提示大眾存在一定的樂觀或僥幸心理，54.9%認為自己比別人患肺結(jié)核的可能性小。調(diào)查顯示，肺結(jié)核外部病恥感22.6分（0-50分范圍），主要表現(xiàn)為與肺結(jié)核患者保持距離；內(nèi)部病恥感總分為20.8分（0-50分范圍），其中“別人會避開我”、“配偶或男女朋友不會與我同住”、“別人會瞧不起我”以及“即使治好了找工作都很困難”為前四項；負面情緒（緊張、害怕和擔(dān)心）得分為3.6分（1-5分范圍）。 研究表明，肺結(jié)核知識與內(nèi)部病恥感、嚴重性認知正相關(guān)（r分別為0.11和0.13），與易感性和風(fēng)險認知及外部病恥感無相關(guān)關(guān)系；外部病恥感與嚴重性認知正相關(guān)（r=0.14），與易感性和風(fēng)險認知負相關(guān)（r分別為-0.21、-0.13）；而內(nèi)部病恥感只與嚴重性認知正相關(guān)（r=0.18）；病恥感兩部分之間正相關(guān)（r=0.52）；負面情緒與外部、內(nèi)部病恥感正向中度相關(guān)(r介于0.37-0.43之間)，與嚴重性認知正向弱相關(guān)(r介于0.12-0.16之間)。 結(jié)論：被調(diào)查的居民肺結(jié)核相關(guān)知識知曉率達到衛(wèi)生部“十一五”結(jié)核病防治規(guī)劃要求，對于肺結(jié)核的風(fēng)險認知與對慢性疾�。ò滩�、心梗、高血壓、糖尿病）、急性疾病或狀況（禽流感、普通感冒、食物中毒）的水平相當(dāng)，存在肺結(jié)核的病恥感和負面情緒。 第二部分傳染性肺結(jié)核患者密切接觸者篩查風(fēng)險傳播干預(yù) 目的：密切接觸者篩查是主動發(fā)現(xiàn)肺結(jié)核患者的有效手段，但在我國不被重視。本部分將探討實施風(fēng)險傳播綜合干預(yù)對提高肺結(jié)核患者配合度，促進其密切接觸者接受臨床篩查、提高肺結(jié)核病例發(fā)現(xiàn)的作用。 方法：以南山區(qū)2011年登記管治的15周歲以上的傳染性肺結(jié)核患者（涂陽、培陽和涂陰空洞）為研究對象，以其登記管治月份為單位將其分為干預(yù)和對照組（285名患者參與，其中對照組135人，干預(yù)150人）；對照組則按照國家結(jié)核病控制指南實施常規(guī)篩查——接受門診醫(yī)師口頭問詢，督導(dǎo)醫(yī)師不參與；干預(yù)組采用督導(dǎo)醫(yī)師強化宣教、發(fā)放篩查預(yù)約單、短信提醒及經(jīng)濟激勵等綜合干預(yù)措施。 結(jié)果：干預(yù)組病人調(diào)查階段共識別623名密切接觸者，平均每名患者4.2名，高于國家指南預(yù)期的3名（P0.001）；風(fēng)險傳播干預(yù)組有密切接觸者到位的患者比例為36.7%（55名），遠高于對照組9.6%（13名）（OR=3.304，P=0.001）；平均每名患者密切接觸者篩查數(shù)，風(fēng)險傳播干預(yù)及對照組分別為0.7和0.1（IRR=3.205，P0.001）。經(jīng)臨床檢查，干預(yù)組發(fā)現(xiàn)31名肺結(jié)核病例（其中2名臨床確診患者、29名結(jié)核菌隱性感染），對照組只發(fā)現(xiàn)了7名結(jié)核菌隱性感染；對于每名患者發(fā)現(xiàn)二代肺結(jié)核病例來說，兩組差異具有統(tǒng)計學(xué)意義（0.2VS0.1，P0.001）�；颊咧型扑]密切接觸者的意愿平均為72.3%，其中推薦家人篩查意愿最高（91.7%）；推薦密切接觸者篩查障礙中，預(yù)期會丟失工作、其他人會遠離自己及失去經(jīng)濟來源排在前三位。 結(jié)論：通過督導(dǎo)醫(yī)師強化宣教、發(fā)放篩查預(yù)約單、短信提醒及經(jīng)濟激勵等干預(yù)措施促進了患者推薦其密切接觸者接受篩查，提高了密切接觸者識別和病例發(fā)現(xiàn)；患者內(nèi)心恥辱感是影響患者推薦的障礙。在保障患者工作權(quán)、平衡患者隱私權(quán)與他人健康權(quán)等的前提下，如何有效開展流動人口密切接觸者篩查，以及提高密切接觸者配合度的措施，是今后進行研究的問題。 第三部分流動人口肺結(jié)核患者跨區(qū)域轉(zhuǎn)診風(fēng)險傳播干預(yù) 目的：跨區(qū)域轉(zhuǎn)診現(xiàn)象在確診的流動人口肺結(jié)核患者中經(jīng)常發(fā)生，容易造成患者治療不規(guī)范甚至中斷治療，給肺結(jié)核控制帶來很大困難；中國肺結(jié)核跨區(qū)域轉(zhuǎn)診率雖只有3%，卻占據(jù)治療效果不理想（死亡、治療失敗、丟失等）的一半。本部分將研究風(fēng)險傳播措施在提高流動人口肺結(jié)核患者治療的連貫性與治愈率的作用。 方法：以南山區(qū)內(nèi)登記管治的流動人口肺結(jié)核患者為對象，采用干預(yù)前后對照類試驗方法；2007年10月-2008年9月（干預(yù)前）采用全球基金《跨區(qū)域肺結(jié)核患者管理程序》的方法；2008年10月-2009年9月（風(fēng)險傳播干預(yù)一期），執(zhí)行包括“以提高患者治療依從性的強化健康教育和醫(yī)患交流、治療期強化監(jiān)督、跨區(qū)域轉(zhuǎn)診協(xié)助及追蹤和加強轉(zhuǎn)入地密切聯(lián)系”在內(nèi)的綜合干預(yù)；2009年10月-2011年9月（風(fēng)險傳播干預(yù)二期），在干預(yù)一期基礎(chǔ)上加強對轉(zhuǎn)入地結(jié)核病防治機構(gòu)干預(yù)，建立了與全國絕大部分縣市機構(gòu)的QQ聯(lián)絡(luò)平臺，實時與轉(zhuǎn)入地聯(lián)絡(luò)（提醒對方落實轉(zhuǎn)出患者的轉(zhuǎn)診追蹤，與其工作人員交流“中國疾病預(yù)防控制系統(tǒng)-轉(zhuǎn)診管理”的操作），采用經(jīng)濟激勵措施（轉(zhuǎn)入地采取“代管”方式管理患者，則轉(zhuǎn)給結(jié)核病防治機構(gòu)代管病人管理費）。 結(jié)果：南山區(qū)4年共管治流動人口肺結(jié)核患者2244名，總轉(zhuǎn)出率為17.1%，其中干預(yù)一期、干預(yù)二期轉(zhuǎn)出率分別為18.5%（110名）、16.1%（179名），與干預(yù)前轉(zhuǎn)出率17.5%（94名）接近（P=0.439）。干預(yù)前，只有39.4%的患者離深時提前告知醫(yī)務(wù)人員，，干預(yù)一期上升到61.8%，二期達到86.5%，年均增幅為30.0%（P0.001）；轉(zhuǎn)診到位率從51.1%提升到2011年的85.5%，年均增幅為18.7%；四年內(nèi)重登率絕對值下降了69%，年均降幅為32.1%；轉(zhuǎn)出患者治愈或完成治療率從4.3%增長到59.8%，但低于流動人口患者整體治愈率（86.0%）。 結(jié)論：跨區(qū)域轉(zhuǎn)診管理風(fēng)險傳播綜合干預(yù)措施-強化健康教育與醫(yī)患交流、療程關(guān)鍵點監(jiān)管、轉(zhuǎn)診協(xié)助及與異地結(jié)核病防治機構(gòu)交流溝通，能提高流動人口肺結(jié)核患者治療的連貫性與治療效果，但是不能減少患者轉(zhuǎn)診的發(fā)生；需要加強對流動人口的關(guān)懷、減少肺結(jié)核患者的經(jīng)濟負擔(dān)。 創(chuàng)新性： 1.以定量的方法測量居民肺結(jié)核風(fēng)險認知和病恥感現(xiàn)狀，并分析它們的相關(guān)性； 2.應(yīng)用風(fēng)險傳播方法針對肺結(jié)核防治的瓶頸問題——肺結(jié)核病例發(fā)現(xiàn)不及時、流動人口跨區(qū)域轉(zhuǎn)診——進行干預(yù)，并有一定的突破，如促進了傳染性肺結(jié)核密切接觸者篩查的實施、提高了病例早期發(fā)現(xiàn)數(shù)和實現(xiàn)了流動人口跨區(qū)域患者治療的延續(xù)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 .

【學(xué)位授予單位】：華中科技大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R521

【參考文獻】

相關(guān)期刊論文 前10條

1 曾偉;張冬梅;鳳

本文編號：1703455