本文關(guān)鍵詞： 婚檢醫(yī)學(xué)檢查 健康信念理論 合理行為理論 多水平模型 Logistic回歸 結(jié)構(gòu)方程模型 社會(huì)贊許性量表　出處：《浙江大學(xué)》2012年博士論文　論文類型：學(xué)位論文

【摘要】：婚前醫(yī)學(xué)檢查是預(yù)防和減少出生缺陷和殘疾發(fā)生的重要措施之一。同時(shí),還具有常見病篩檢功能和早發(fā)現(xiàn)、早診斷、早治療的作用。2003年新《婚姻登記條例》將“強(qiáng)制婚檢”改為“自愿婚檢”后,各地婚檢率急劇下滑。本文根據(jù)自愿婚檢的行為特征和可能的影響因素,篩選和互補(bǔ)國外相關(guān)健康行為理論,在整合和互補(bǔ)健康行為理論(HBM)和合理行動(dòng)理論(TRA)等相關(guān)維度的基礎(chǔ)上,從理論構(gòu)造、選擇理由等方面提出適合我國婚檢依從行為解釋和干預(yù)的理論假設(shè)模型,并提出數(shù)個(gè)假說,通過多水平多因素Logistic回歸模型(MLwiN2.02軟件)和結(jié)構(gòu)方程模型(LISREL8.71統(tǒng)計(jì)軟件)進(jìn)行實(shí)證研究。 在明確各維度操作定義的基礎(chǔ)上,經(jīng)過婚姻登記新人定性訪談、建立題項(xiàng)庫、專家評(píng)價(jià)、預(yù)試驗(yàn)、信度和效度檢驗(yàn)等程序設(shè)計(jì)調(diào)查問卷,采用148個(gè)預(yù)試樣本進(jìn)行量表?xiàng)l目分析和598個(gè)預(yù)試樣本進(jìn)行量表信度和效度檢驗(yàn)。 采用分層隨機(jī)抽樣方法,按照地理分布、經(jīng)濟(jì)水平和文化特征等因素選擇浙江省有代表性的12個(gè)縣(市、區(qū))作為調(diào)查點(diǎn),樣本量為2572人。采用598個(gè)預(yù)試樣本進(jìn)行結(jié)構(gòu)方程模型預(yù)試驗(yàn),然后利用2572個(gè)擴(kuò)展樣本進(jìn)行多水平多因素Logistic回歸模型和結(jié)構(gòu)方程模型擴(kuò)展驗(yàn)證。為研究社會(huì)贊許性對(duì)婚檢依從行為影響結(jié)構(gòu)的影響,將2572個(gè)擴(kuò)展樣本按社會(huì)贊許性量表得分(分割點(diǎn)7/13)分成高、低兩組,用結(jié)構(gòu)方程模型進(jìn)行交叉驗(yàn)證,最終以社會(huì)贊許性低組別(n=777)結(jié)構(gòu)方程模型作為本文的研究結(jié)果。 本文的研究結(jié)果主要包括： 一是婚檢意向和婚檢行為的關(guān)系�；闄z意向人群中75%采納了婚檢行為,有婚檢意向而沒有去婚檢的人群占總數(shù)的19.4%,無婚檢意向且沒有去婚檢的人群占總數(shù)的2.6%。結(jié)構(gòu)方程模型驗(yàn)證顯示,婚檢意向?qū)闄z行為的標(biāo)準(zhǔn)化路徑系數(shù)為0.75(T=22.15,p0.01)。 二是行為態(tài)度、主觀規(guī)范、威脅感對(duì)婚檢意向的作用。行為態(tài)度對(duì)婚檢意向的標(biāo)化路徑系數(shù)為0.48(T=8.81,p0.01)；主觀規(guī)范對(duì)婚檢意向的直接標(biāo)化路徑系數(shù)為0.22(T=4.75,p0.01),間接標(biāo)化路徑系數(shù)為0.14,兩者合計(jì)為0.36；威脅感對(duì)婚檢意向的標(biāo)化路徑系數(shù)為-0.08(T=2.20,p=0.078)。 三是婚檢益處感、障礙感對(duì)婚檢行為態(tài)度的作用。障礙感對(duì)婚檢行為態(tài)度的標(biāo)化路徑系數(shù)為-0.16(T=4.45,p0.01),益處感對(duì)婚檢行為態(tài)度的標(biāo)化路徑系數(shù)為0.52(T=11.98,p0.01)。 四是益處感與婚檢行為的虛假直接因果關(guān)系。益處感對(duì)婚檢行為的沒有直接因果關(guān)系(標(biāo)化r=-0.02,p=0.284)。在大樣本中(n=2572)益處感對(duì)婚檢的標(biāo)化路徑系數(shù)為-0.16(T=-2.49,p0.01),其虛假聯(lián)系主要是由社會(huì)贊許性高引起的。 五是危機(jī)感、嚴(yán)重感對(duì)威脅感的作用。危機(jī)感對(duì)威脅感的標(biāo)化路徑系數(shù)為0.89(T=37.74,p0.01),嚴(yán)重感對(duì)威脅感的標(biāo)化路徑系數(shù)為0.52(T=33.59,p0.01)。 六是婚檢規(guī)范信念、遵從動(dòng)機(jī)對(duì)婚檢主觀規(guī)范的作用�；闄z規(guī)范信念對(duì)主觀規(guī)范的標(biāo)化路徑系數(shù)為0.64(T=30.59,p0.01),遵從動(dòng)機(jī)對(duì)主觀規(guī)范的標(biāo)化路徑系數(shù)為0.46(T=28.08,p0.01)。 七是地域因素(主要是環(huán)境政策)對(duì)婚檢行為的作用。多水平多因素Logistic回歸模型顯示,各變量(含啞變量和截距)的方差成分系數(shù)VPC范圍為15.40%-17.58%,因此地域環(huán)境因素對(duì)婚檢行為的影響力約占16%。 八是年齡、性別、教育水平、職業(yè)等作為外部間接變量對(duì)婚檢行為的影響。多水平多因素Logistic回歸模型顯示,不同性別、年齡、戶籍、教育程度、收入、醫(yī)療保險(xiǎn)類型、是否曾婚檢過等人群間的婚檢率差異沒有統(tǒng)計(jì)學(xué)意義。不同職業(yè)、近6個(gè)月內(nèi)是否參加過體檢、結(jié)婚登記類型等人群間的婚檢率差異具有顯著性。企業(yè)職工(國有/非公/私營)、個(gè)體工商戶、農(nóng)業(yè)勞動(dòng)者的婚檢率比行政事業(yè)單位員工要高,OR值分別為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個(gè)月內(nèi)無醫(yī)學(xué)體檢人群婚檢率是醫(yī)學(xué)體檢人群的1.31倍(95%CI：1.05～1.65)；與初婚未孕人群相比,初婚已孕和再婚人群婚檢率是其1.51倍(95%CI：1.14～2.00)和0.35倍(95%CI：0.23～0.51)。 本文的主要結(jié)論： 一是婚檢行為主要受行為態(tài)度、主觀規(guī)范、威脅感等通過婚檢意向間接影響,其中又以行為態(tài)度、主觀規(guī)范為主；外部政策環(huán)境對(duì)婚檢行為有影響但較小(約占總方差的16%)；個(gè)體的性別、年齡、戶籍、教育程度、收入、醫(yī)療保險(xiǎn)類型、是否曾婚檢過等人口學(xué)變量對(duì)婚檢沒有影響,職業(yè)、體檢史、結(jié)婚登記類型等有影響,結(jié)合理論和文獻(xiàn),其影響可能是通過影響行為態(tài)度、主觀規(guī)范、威脅感等維度間接作用于意向或行為。 二是社會(huì)贊許性會(huì)對(duì)婚檢行為影響因素的網(wǎng)狀結(jié)構(gòu)產(chǎn)生影響,特別是益處感和障礙感等婚檢行為態(tài)度對(duì)婚檢行為的影響,但社會(huì)贊許性對(duì)危機(jī)感、嚴(yán)重感、規(guī)范信念、遵從動(dòng)機(jī)影響較小。結(jié)合中國“關(guān)系”、“面子”和“跟風(fēng)”等文化或行為特性,建議在研制中國問卷調(diào)查量表時(shí)(特別是益處感等),要考慮社會(huì)贊許性評(píng)價(jià)和修正。 本文的政策建議(按優(yōu)先次序)是： 一是通過倡導(dǎo)婚檢的社會(huì)規(guī)范和婚檢決策影響力人群(如家庭、醫(yī)生、社區(qū)婦女干部等)的作用,強(qiáng)化社區(qū)動(dòng)員,婚檢干預(yù)往往會(huì)取得事半功倍的效果。 二是努力消除婚檢行為的障礙,如合理布局婚檢點(diǎn)和婚檢項(xiàng)目,優(yōu)化婚檢流程,保護(hù)婚檢對(duì)象的相關(guān)隱私,充分宣傳免費(fèi)婚檢的政策,倡導(dǎo)“婚登與婚檢一條龍”服務(wù)模式,優(yōu)化各類體檢和婚檢的合理銜接(如單位體檢中增設(shè)婚檢內(nèi)容,憑檢查結(jié)果由政府進(jìn)行補(bǔ)貼)；提供溫馨就診環(huán)境,強(qiáng)化人性化服務(wù)、個(gè)體化服務(wù)并通過“同伴宣傳效應(yīng)”吸引更多婚齡青年婚檢。 三是從正面引導(dǎo)和宣傳婚檢的知識(shí)和好處。四是對(duì)不同的職業(yè)、近6個(gè)月內(nèi)是否參加過體檢、結(jié)婚登記類型(如初婚未孕、初婚已孕和再婚等)等不同人群,采用分類指導(dǎo)、屬地化、個(gè)性化的干預(yù)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 . ) .

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2012
【分類號(hào)】：R169.1

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