本文選題：流產后計劃生育服務　切入點：影響因素探索　出處：《北京協(xié)和醫(yī)學院》2013年博士論文　論文類型：學位論文

【摘要】：[研究目的] 一、總目的 對我國三城市流產后計劃生育服務質量的影響因素進行探索(簡稱“影響因素探索”),并對三城市的流產后計劃生育服務質量進行綜合評價(簡稱“質量綜合評價”),為優(yōu)質的流產后計劃生育服務的進一步開展提供參考。 二、具體目的 (一)利用重復流產率、避孕措施落實、性與生殖健康知識水平及服務滿意度四大類國際上常用的流產項目評估指標的影響因素分析結果,結合構建的婦女流產后避孕行為影響因素的驗證性因子分析SEM,從流產后計劃生育服務質量提高的目的(防止非意愿妊娠的發(fā)生,降低流產率和重復流產率)出發(fā),探索影響流產后計劃生育服務質量的因素,并提出相應的對策。 (二)在WHO優(yōu)質流產后計劃生育服務框架的基礎上,利用綜合評分法、蛛網(wǎng)圖模型法和聚類分析法對北京、上海、鄭州三地區(qū)的29家醫(yī)院的流產后計劃生育服務質量進行綜合評價,探索性地綜合評估我國流產后計劃生育服務質量的優(yōu)勢和不足,并驗證幾種綜合評價方法在流產后計劃生育服務質量評估方面的適用性,為流產后計劃生育服務質量的評估提供參考。 [研究方法] 一、資料來源 本研究是在歐盟FP6中國流產后計劃生育服務研究數(shù)據(jù)基礎上的再分析、再挖掘。數(shù)據(jù)基本情況如下 采用分層隨機化的方法,在北京、上海、鄭州三個城市選擇了29家醫(yī)院。在這29家醫(yī)院中,共調查流產婦女3132人。流產婦女的納入標準為：①到選定的醫(yī)院尋求流產服務；②年齡25歲；③早期妊娠；④能在半年后隨訪,隨訪方式可以為反診或是電話隨訪；⑤愿意參加本調查。排除標準為：不愿參加本研究者或不能堅持隨訪者。 二、研究方法 在服務質量影響因素探索方面,本文綜合運用了傳統(tǒng)經典的統(tǒng)計方法及現(xiàn)代統(tǒng)計學方法。使用的經典統(tǒng)計分析方法主要包括描述性分析、χ2檢驗、Logistic回歸及多元線性回歸等。使用的現(xiàn)代統(tǒng)計學方法是新一代統(tǒng)計學三大進展中的最突出代表：SEM。 在服務質量綜合評價方面,主要在WHO的優(yōu)質流產后計劃生育服務框架的基礎上,探索性的采用了綜合評價法中的綜合評分法、蛛網(wǎng)圖評價法和聚類分析法,對服務質量進行了綜合評估。 在本研究數(shù)據(jù)的統(tǒng)計分析及綜合評價中,主要采用SPSS17.0軟悠揚；在SEM構建的過程中,首先采用SPSS17.0軟件對數(shù)據(jù)進行插補,在數(shù)據(jù)插補完成后采用AMOS軟件進行SEM的構建；在綜合評價中的蛛網(wǎng)圖評價法中,采用了Microsoft Office軟件進行了模型圖的構建。 [研究結果] 一、影響因素探索部分 (一)國際上常用的四大類流產項目評估指標的影響因素分析 1.重復流產 (1)流產婦女的妊娠原因 未避孕(64.0%)和避孕失敗(36.0%)是本次調查中3132名流產婦女的主要妊娠原因。婦女不避孕的主要原因是“在沒有準備好避孕藥具的情況下進行了同房”(43.3%)和“因為知道但不想使用避孕方法”(34.6%)。絕大多數(shù)避孕失敗的發(fā)生是在使用短效的現(xiàn)代避孕措施(避孕套39.2%、緊急避孕藥20.1%、口服避孕藥12.4%)中和傳統(tǒng)的避孕措施(安全期29.7%,體外射精20.1%)中,在使用長效避孕措施(宮內節(jié)育器1.5%)中發(fā)生避孕失敗的較少。 (2)重復流產的影響因素 多因素Logistic回歸分析發(fā)現(xiàn),知識得分和性生活時間與重復流產的發(fā)生有關,與知識得分60分的婦女相比,知識得分≥60分的婦女重復流產的發(fā)生相對較少(OR95%CI：0.694(0.498-0.969)；在性生活時間方面,與性生活時間1年的相比,性生活時間≥1年的婦女發(fā)生重復流產的可能越大(OR95%CI：29.44(15.327-56.548))。 2.性與生殖健康知識 多因素Logistic回歸分析發(fā)現(xiàn),年齡和出生地是性與生殖健康知識水平的影響因素,與年齡22歲的婦女相比,年齡≥22的婦女,在性與生殖健康知識方面及格率越高(OR95%CI:1.625(1.164-2.270));與出生在農村的婦女相比,出生在城鎮(zhèn)(OR95%CI：1.800(1.241-2.611))和城市(OR95%CI：1.554(1.102-2.190))的婦女性與生殖健康知識方面及格率越高。 3.避孕措施 (1)流產婦女避孕措施的使用情況 流產前和流產后,婦女使用的主要的避學措施均為避孕套(前：77.5%,后：78.2%)和體外射精(前：11.6%,后：7.7%)。 (2)流產婦女避孕藥具選擇時各因素的考慮情況 在避孕藥具的選擇時,婦女最關注的為避孕措施的安全性(74.6%)和有效性(70.0%),最不關注的為避孕藥具的價格(10.5%)。 (3)流產后首次性生活避孕措施落實的影響因素 多因素Logistic回歸分析發(fā)現(xiàn),婚姻狀況、男方是否關心避孕問題、男女年齡差距和性生活時間與流產后首次性生活時避孕措施的落實情況相關。與男方不關心避孕問題的相比,男方關系避孕問題的婦女流產后首次性生活時避孕措施的落實率高(OR95%CI：1.413(1.102-1.812))；與性生活時間1年的相比,性生活時間≥1年的婦女流產后首次性生活時避孕措施的落實率高(OR95%CI：1.382(1.076-1.774))；與已婚的婦女相比,未婚的婦女流產后首次性生活時避孕措施的落實率低(OR95%CI：0.66(0.498-0.875))；與男女年齡差距2歲的相比,男女年齡差距≥2的婦女流產后首次性生活時避孕措施的落實率低(OR95%CI：0.749(0.593-0.946))。 (4)各類避孕措施使用的影響因素 影響避孕套、口服避孕藥、IUD、緊急避孕藥、傳統(tǒng)/現(xiàn)代避孕措施、短效/長效避孕措施使用的多因素Logistic回歸分析結果見匯總表ST-I。 (二)婦女流產后避孕行為影響因素的驗證性因子分析SEM構建結果 采用AMOS17.0擬合的SEM結果見圖SF-1,圖中所有的路徑系數(shù)均為標準化后的路徑系數(shù)。模型的擬合結果顯示χ2=841.782(P0.05),GFI=0.969, AGFI=0.949, PGFI=0.596,盡管P值小于0.05,但由本研究擬合的GFI、AGFI和PGFI非常理想,所以認為模型對數(shù)據(jù)的擬合程度較高。SEM分析結果顯示,性與生殖健康知識、個體因素、社會經濟地位、社會支持等潛變量均會通過直接和/或間接的途徑來影響婦女流產后的避孕行為。 注： 1.為簡潔明了,本表只匯總了多因素分析有意義的變量： 2.口服避孕藥單因素分析沒有P0.05的變量,因此不進行多因素分析,故在本表中未納入口服避孕藥的結果； 3.自變量賦值：年齡：1=22歲(ref),2=≥22歲；男性年齡分組：1=24歲(ref),2=≥24歲；性生活時間：1=1年(ref)2=≥1年；其余自變量:0=否(ref),1=是 4.因變量賦值避孕套(0=不使用；1=使用)；宮內節(jié)育器(0=不使用；1=使用)；緊急避孕藥(0=不使用；1=使用)；傳統(tǒng)/現(xiàn)代避孕措施(0=傳統(tǒng)；1=現(xiàn)代)；短效/長效避孕措施(0=短效：1=長效)。 二、質量綜合評價部分 綜合評分法結果顯示,我國三城市的流產后計劃生育服務質量在人際關系(82.17分)和服務的連續(xù)性(82.66分)方面相對較好,在服務時機(57.67分)、避孕方法的選擇(62.85分)、技術力量(57.26分)方面的能力次之,在宣教和咨詢方面的能力最弱(48.46分)：上海、北京、鄭州三地區(qū)的綜合得分分別為72.33、61.84和57.32分。 蛛網(wǎng)圖評價法結果顯示,三城市的服務質量在WHO優(yōu)質流產后計劃生育服務框架的六個方面有很好的一致性。 聚類分析結果顯示,納入研究的29家醫(yī)院的流產后計劃生育服務質量總體可分高、中、低三類,各類中的醫(yī)院數(shù)目分別為9、12和8家。 [研究結論] 一、影響因素探討部分 探討流產后計劃生育服務質量的影響因素,提高流產后計劃生育服務質量的目的是降低流產及重復流產的發(fā)生率。非意愿妊娠是流產和重復流產發(fā)生的根源,要解決流產和重復流產問題,需要從非意愿妊娠發(fā)生的主要原因來入手。因此,提高流產后計劃生育服務的質量,解決流產和重復流產問題,主要需從優(yōu)化避孕藥具提供網(wǎng)絡、改變婦女“不想使用避孕方法”的態(tài)度和解決避孕失敗問題三大方面來進行。 提高年輕化、未育化的流產人群的避孕藥可及性,是避孕藥具網(wǎng)絡優(yōu)化的一大切入點；改變流產婦女“不想使用避孕方法”的態(tài)度,不僅需要提高流產婦女的性與生殖健康知識水平,還需要改善外界環(huán)境的影響,如增加男方在避孕節(jié)育和流產服務中的參與等；要解決“避孕失敗”問題,需要通過宣教、咨詢等各種措施,來提高流產婦女的避孕相關知識水平和避孕技能,來減少安全期和體外射精等傳統(tǒng)避孕方法的使用,提高各類短效現(xiàn)代避孕措施的正確使用率和堅持使用率,增加長效現(xiàn)代避孕措施的使用率。 婦女流產后避孕行為影響因素的SEM構建結果顯示,婦女流產后避孕行為的改變,受到多種因素共同作用的影響。因此,要改變婦女流產后的避孕行為,不能僅僅依靠一種因素的改變。而是要協(xié)調采用多種措施,綜合提高流產后的計劃生育服務質量,以達到預防非意愿妊娠發(fā)生,進而達到降低流產率和重復流產率的目的。 二、質量綜合評價部分 從WHO的優(yōu)質流產后計劃生育服務框架的六方面來看,我國三城市的流產后計劃生育服務質量在人際關系和服務的連續(xù)性方面相對較好,在服務時機、避孕方法的選擇、技術力量方面的能力次之,在宣教和咨詢方面的能力最弱。三城市的服務質量在WHO優(yōu)質流產后計劃生育服務框架的六方面有很好的一致性。 綜合評分法和聚類分析法兩種評估結果的一致性,不僅驗證了本研究中質量綜合評價結果的可靠性和穩(wěn)定性,同時說明了兩種方法在醫(yī)院流產后計劃生育服務質量的綜合評價上是適用的。
[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.

【學位授予單位】：北京協(xié)和醫(yī)學院
【學位級別】：博士
【學位授予年份】：2013
【分類號】：R169.4

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