【作者】 周驰；

【导师】 李鲁；

【作者基本信息】 浙江大学 ， 社会医学与卫生事业管理， 2012， 博士

【摘要】 研究背景婚前医学检查是保障母婴健康,减少出生缺陷,提高出生人口素质的一级预防措施。自2003年新《婚姻登记条例》正式实施以来,婚检从强制变成自愿选择,各地婚检人数大幅度下降,与此同时婚育疾病的检出率却仍在缓慢提升,这一严峻现象已成为当前婚育保健工作的棘手问题。许多省份纷纷推行免费婚检政策来挽救急剧下跌的婚检率,虽取得了一定效果,但与强制时期的婚检率仍差之甚远,很多准新人对免费婚检并不领情。另外,婚检变成由政府埋单免费提供后,各地一味追求婚检率的提高,而婚检的实际实施效果却不尽如人意。准新人在思想上并没有真正重视婚检,虽然参加了婚检,但事后对自己的检查结果却不闻不问、漠不关心。这些重“婚检率”而轻“婚检效果”的现象,违背了婚检作为预防出生缺陷一级措施的目的和意义。因此,如何通过综合有效的干预措施让更多的准新人夫妇自愿参加婚检,并且关心和重视自己的检查结果,切实改善婚检实施的整体效果,是婚育保健工作急需探索解决和值得深入研究的问题。研究目的本研究将以浙江省作为一个样本地区,在健康行为相关理论的指导下,基于前期婚检自愿性行为现状调查和现场定性访谈的基础上,设计婚检自愿性行为的综合干预方案以提高婚检实施的整体效果,评价干预的实际效果和分析干预对婚检自愿性行为的影响路径,并提出改善婚检实施效果的建议。研究方法本研究采用定性和定量相结合的方法收集资料。首先,与20对未参加婚检的夫妇、20对已参加婚检的夫妇,5名婚检中心负责人和婚检医生进行半结构式深入访谈,进而设计婚检自愿性行为综合干预方案。其次,选取杭州市G区婚姻登记处作为干预现场,于2011年6月—10月进行为期五个月的干预研究。在现场拦截准备办理结婚登记但尚未参加婚检的准新人,共调查了458对准新人夫妇(干预组228对,对照组230对)。干预组和对照组人群按年龄、学历、职业、月收入等因素进行匹配。其中干预组开展一系列婚检自愿性行为的综合干预活动,而对照组仅开展常规婚检及结婚登记工作。采用卡方分析比较干预组和对照组在婚检自愿性行为各维度上的差异,运用泊松回归分析婚检自愿性行为的影响因素,通过结构方程模型来观察和解释干预及各干预模块与婚检自愿性行为之间的路径关系和相互作用,应用成本效果分析评估综合干预方案成效。干预方案干预方案在现场观察和定性访谈结果分析的基础上,按照干预路径框架的步骤,再参考健康行为理论等实际应用的文献研究,主要从行为态度(益处感和障碍感)、感知威胁(危机感和严重感)、主观规范等三个方面着手综合设计具体的干预措施及操作流程,通过采取面对面个体宣教的形式来干预其行为意图,从而达到改变婚检自愿性行为、提高婚检实施效果的目的。结果定性分析结果发现浙江省婚检目前存在的问题有：1)民政和婚检部门重视婚检率,忽视婚检结果；2)刻意简化婚检项目、遗漏婚育咨询指导；3)婚检检查结果未进行信息共享,缺少后续跟踪随访；4)婚检宣传医生的宣教方法不科学；5)准新人对婚检的重视度和自觉性有待提高。准新人对婚检的认知态度表现为：1)准新人对婚检的好处已有一个比较全面的认识；2)在参加婚检方面准新人心理上存在“工作忙”和“检查项目繁琐”这两方面的障碍感,在领取婚检报告单方面存在“工作忙没时间领取”的障碍感；3)准新人在主观态度上认同参加婚检和领取婚检报告单的行为,但需进一步帮助准新人树立积极的婚检行为态度,更正他们对婚检和体检混淆的误区；4)准新人对婚育疾病方面的知识了解不足,对其可能造成的严重后果认识不足；5)婚检现场的医生宣教是被准新人普遍接受和认可的途径。定量分析结果发现：1)干预组人群在益处感、障碍感、行为态度、危机感、严重感上的平均得分较对照组明显提高,差异具有统计学意义,且男性和女性两组在构成比上差别不明显；2)对婚检自愿性行为意图的Poisson多元回归分析显示,障碍感越低、行为态度越积极的准新人,行为意图更为强烈；3)对婚检自愿性行为的Poisson多元回归分析显示,行为态度越积极、感知威胁越强烈的准新人,更可能采取实际行动；4)性别、年龄、教育程度、职业、月收入与婚检自愿性行为意图和行为没有相关性；5)结构方程模型分析结果显示,干预活动提高了准新人对于婚检的益处感、降低了对婚检的障碍感、增强了对婚检及检查结果的危机感和严重感,促进了准新人关注婚检结果并及时领取婚检报告单；6)准新人的行为意图受到干预、行为态度和感知威胁的直接影响,准新人的行为受到干预、行为意图的直接影响；7)对照组中准新人的行为主要由婚检益处感决定,而干预组中准新人的行为主要由行为意图决定,行为意图受行为态度和感知威胁两者的直接影响；8)干预措施对男性和女性婚检自愿性行为的益处感、障碍感、危机感、严重感均有直接影响作用,其中干预对女性益处感、障碍感、危机感的直接影响作用要略大于男性,干预对男性严重感的直接影响作用要略大于女性；9)婚检自愿性行为综合干预方案成本低且富有成效。结论通过婚检自愿性行为综合干预的实施,可以提高准新人对婚检的认知水平,树立积极正向的行为意图,提高准新人自愿参加婚检和领取婚检检查结果的行为,有效改善婚检的实施整体效果,并为当前婚育保健工作提出建议参考。更多还原

【Abstract】 BackgroudPremarital medical examination (PME), as the primary prevention measures, used to protect maternal and child health, to reduce birth defects and improve the quality of birth. China introduced the new regulations on marriage registration in2003, and put a start to the voluntary PME. Since then the number of couples undergoing PME had dropped drastically nationwide, but the disease detection rate was still in slow rising, so this grim phenomenon had became the thorny issue of marriage and childbearing care. In order to save the shrap decline rate of PME, the policy of free of charge was carry out in some provinces and had achieved a certain effect. But the situation of PME remained far worse than the mandatory period, and a lot of couples did not appreciate free PME. Plus, local governments were blind pursuit increasing the rate of PME after the free charge policy, but the actual implementation results of PME were not satisfactory. Couples were not truly realize the importance of PME, they didn’t care about their examine results at all. So the PME rate was more important than results, and these phenomenon were contrary to the purpose of primary prevention measure of birth defects. Therefore, the marriage and childbearing care urgent was needed to explore useful comprehensive interventions to let more couples attend PME voluntary, took serious on their examine results and improved the actual effect of PME.AimThis study chose Zhejiang Province as a sample. Based on the prior survey and qualitative data, this study was designed the interventions of PME voluntary behaviors under the guidance of health behavior theory. With implemented these interventions, we hoped to improve the actual effects of PME, evaluated the intervention effects, analysed the path between intervention and voluntary behaviors, and provided related suggestions.MethodsThis study used qualitative and quantitative methods to collect data. Firstly, we interviewed20couples who did not participate in PME,20couples who had participated in PME, and5managers and doctors of PME. Then was designed the comprehensive intervention plan for voluntary behaviors of PME. Secondly, this study selected the Marriage Registry of G as the site of intervention, and the whole intervention was carry out during June to October in2011. Couples were intercepted at the site, which were preparing for marriage registration but had not yet participated in PME. This study investigated a total of458couples, and228couples in intervention group and230couples in control group. Intervention group and control group populations by factors such as age, education, occupation, monthly income to match. Intervention group was carried out a series intervention, while the control group was only carried out routine work. Chi-square analysis was used to compare the differences on each dimension of voluntary behaviors of PME, Poisson regression was used to analysis the influence factors of PME, structural equation modeling was used to explain the path between interventions and voluntary behaviors, and cost-effectiveness analysis was used to assess the intervention programs.Intervention planBased on the site observations and qualitative data analysis, this study designed the specific interventions mainly from attitudes (benefits and barriers), perceived threat (perceived susceptibity, perceived seriousness), subjective norm. The whole intervention plan was designed by the guidance of Intervention Mapping and health behavior theory. This study used the form of face to face to intervene couple’s behavior intentions, try to change the voluntary behaviors and improve the effects of PME.ResultsFrom the qualitative analysis of results, the study was found current problems in PME. Firstly, the department of civil affairs and premarital emphasised on PME rate, and ignored PEM results; Secondly, deliberately simplified the PME project and consulting guidance; Thirdly, PME results were not sharing information, and also lack of follow up; Fourthly, the education ways of doctors were not professional; Fifthly, the attention and consciousness degree of couples needed to be improved. The cognitive attitudes of couples were as follows. Firstly, couples had a comprehensive understanding on PME benefits; Secondly, there exist two barriers,"busy work" and "complex examine items", in couple’s mind to participate in PME. And couples had a barrier with "busy work and no time to get results" on getting PEM report; Thirdly, couples agreed to participate in PME on the subjective attitude, but still needed further help to establish a more positive behavior attitude, and corrected errors that they confuse the PME and physical examination; Fourthly, couples with lack of knowledge about diseases, could make them not take serious on the possible consequences; Fifthly, the way that doctors educate couples in site was generally accepted.From the quantitative analysis of results, this study found out as follows. Firstly, the intervention group had a higher average score on benefits, barriers sense, behavior attitude, perceived susceptibility, and perceived severity than control group. The two groups had a statistically significant difference. There was no significant difference between men and women in composition of each variable. Secondly, the results of Poisson regression on PME voluntary behavior intentions showed that, couples with lower barriers and more positive behavior attitudes could have more strongly behavior intention. Thirdly, the results of Poisson regression on PME voluntary behavior showed that, couples with more positive behavior attitudes and perceived threat were more likely to take practical action. Fourthly, factors, like gender, age, education, occupation and income, had no correlation with PME voluntary behavior intention and behavior. Fifthly, the results of structural equation modeling analysis showed that interventions can increase benefits, perceived susceptibility and perceived severity, and reduce barriers. The interventions could promote couples concerned about their PME results and take the result report timely. Sixthly, interventions, behavior attitudes and perceived threat played a direct impact on couple’s behavior intentions. Interventions, behavior intentions played a direct impact on couple’s behavior. Seventhly, couple’s behavior in control groups was mainly determined by benefits, and in intervention groups was by behavior intentions. Behavior attitudes and perceived threat could play a direct impact on behavior intentions. Eighthly, interventions played a direct impact on behaviors, barriers, perceived susceptibility and perceived severity in both males and females. And the impacts on female’s benefits, barriers and perceived susceptibility were slightly larger than males, but the impacts on male’s perceived severity were slightly larger than females. Ninthly, this intervetion program had a good economic effect.ConclusionAfter implementing interventions of voluntary behaviors on PME, the cognitive level of couples could be improved, and the positive behavioral intention chould be established. Plus, these interventions were increasing the rate of PME and the behavior of getting results, and also improved the actual effects of PME. These effect interventions could provide a reference for the current marriage and childbearing health care.更多还原