【作者】 顾亚明；

【导师】 李鲁； 杨廷忠；

【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】 婚前医学检查是预防和减少出生缺陷和残疾发生的重要措施之一。同时,还具有常见病筛检功能和早发现、早诊断、早治疗的作用。2003年新《婚姻登记条例》将“强制婚检”改为“自愿婚检”后,各地婚检率急剧下滑。本文根据自愿婚检的行为特征和可能的影响因素,筛选和互补国外相关健康行为理论,在整合和互补健康行为理论(HBM)和合理行动理论(TRA)等相关维度的基础上,从理论构造、选择理由等方面提出适合我国婚检依从行为解释和干预的理论假设模型,并提出数个假说,通过多水平多因素Logistic回归模型(MLwiN2.02软件)和结构方程模型(LISREL8.71统计软件)进行实证研究。在明确各维度操作定义的基础上,经过婚姻登记新人定性访谈、建立题项库、专家评价、预试验、信度和效度检验等程序设计调查问卷,采用148个预试样本进行量表条目分析和598个预试样本进行量表信度和效度检验。采用分层随机抽样方法,按照地理分布、经济水平和文化特征等因素选择浙江省有代表性的12个县(市、区)作为调查点,样本量为2572人。采用598个预试样本进行结构方程模型预试验,然后利用2572个扩展样本进行多水平多因素Logistic回归模型和结构方程模型扩展验证。为研究社会赞许性对婚检依从行为影响结构的影响,将2572个扩展样本按社会赞许性量表得分(分割点7/13)分成高、低两组,用结构方程模型进行交叉验证,最终以社会赞许性低组别(n=777)结构方程模型作为本文的研究结果。本文的研究结果主要包括：一是婚检意向和婚检行为的关系。婚检意向人群中75%采纳了婚检行为,有婚检意向而没有去婚检的人群占总数的19.4%,无婚检意向且没有去婚检的人群占总数的2.6%。结构方程模型验证显示,婚检意向对婚检行为的标准化路径系数为0.75(T=22.15,p<0.01)。二是行为态度、主观规范、威胁感对婚检意向的作用。行为态度对婚检意向的标化路径系数为0.48(T=8.81,p<0.01)；主观规范对婚检意向的直接标化路径系数为0.22(T=4.75,p<0.01),间接标化路径系数为0.14,两者合计为0.36；威胁感对婚检意向的标化路径系数为-0.08(T=2.20,p=0.078)。三是婚检益处感、障碍感对婚检行为态度的作用。障碍感对婚检行为态度的标化路径系数为-0.16(T=4.45,p<0.01),益处感对婚检行为态度的标化路径系数为0.52(T=11.98,p<0.01)。四是益处感与婚检行为的虚假直接因果关系。益处感对婚检行为的没有直接因果关系(标化r=-0.02,p=0.284)。在大样本中(n=2572)益处感对婚检的标化路径系数为-0.16(T=-2.49,p<0.01),其虚假联系主要是由社会赞许性高引起的。五是危机感、严重感对威胁感的作用。危机感对威胁感的标化路径系数为0.89(T=37.74,p<0.01),严重感对威胁感的标化路径系数为0.52(T=33.59,p<0.01)。六是婚检规范信念、遵从动机对婚检主观规范的作用。婚检规范信念对主观规范的标化路径系数为0.64(T=30.59,p<0.01),遵从动机对主观规范的标化路径系数为0.46(T=28.08,p<0.01)。七是地域因素(主要是环境政策)对婚检行为的作用。多水平多因素Logistic回归模型显示,各变量(含哑变量和截距)的方差成分系数VPC范围为15.40%-17.58%,因此地域环境因素对婚检行为的影响力约占16%。八是年龄、性别、教育水平、职业等作为外部间接变量对婚检行为的影响。多水平多因素Logistic回归模型显示,不同性别、年龄、户籍、教育程度、收入、医疗保险类型、是否曾婚检过等人群间的婚检率差异没有统计学意义。不同职业、近6个月内是否参加过体检、结婚登记类型等人群间的婚检率差异具有显著性。企业职工(国有/非公/私营)、个体工商户、农业劳动者的婚检率比行政事业单位员工要高,OR值分别为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个月内无医学体检人群婚检率是医学体检人群的1.31倍(95%CI：1.05～1.65)；与初婚未孕人群相比,初婚已孕和再婚人群婚检率是其1.51倍(95%CI：1.14～2.00)和0.35倍(95%CI：0.23～0.51)。本文的主要结论：一是婚检行为主要受行为态度、主观规范、威胁感等通过婚检意向间接影响,其中又以行为态度、主观规范为主；外部政策环境对婚检行为有影响但较小(约占总方差的16%)；个体的性别、年龄、户籍、教育程度、收入、医疗保险类型、是否曾婚检过等人口学变量对婚检没有影响,职业、体检史、结婚登记类型等有影响,结合理论和文献,其影响可能是通过影响行为态度、主观规范、威胁感等维度间接作用于意向或行为。二是社会赞许性会对婚检行为影响因素的网状结构产生影响,特别是益处感和障碍感等婚检行为态度对婚检行为的影响,但社会赞许性对危机感、严重感、规范信念、遵从动机影响较小。结合中国“关系”、“面子”和“跟风”等文化或行为特性,建议在研制中国问卷调查量表时(特别是益处感等),要考虑社会赞许性评价和修正。本文的政策建议(按优先次序)是：一是通过倡导婚检的社会规范和婚检决策影响力人群(如家庭、医生、社区妇女干部等)的作用,强化社区动员,婚检干预往往会取得事半功倍的效果。二是努力消除婚检行为的障碍,如合理布局婚检点和婚检项目,优化婚检流程,保护婚检对象的相关隐私,充分宣传免费婚检的政策,倡导“婚登与婚检一条龙”服务模式,优化各类体检和婚检的合理衔接(如单位体检中增设婚检内容,凭检查结果由政府进行补贴)；提供温馨就诊环境,强化人性化服务、个体化服务并通过“同伴宣传效应”吸引更多婚龄青年婚检。三是从正面引导和宣传婚检的知识和好处。四是对不同的职业、近6个月内是否参加过体检、结婚登记类型(如初婚未孕、初婚已孕和再婚等)等不同人群,采用分类指导、属地化、个性化的干预策略。更多还原

【Abstract】 Premarital medical examination (PME) used to be compulsory by the marriage law in China. Its main purpose was to screen for genetic disorders, sexually transmitted diseases, hepatitis B and conditions that may jeopardize parenting abilities, such as psychiatric problems. China introduced the new regulations on marriage registration in2003, and put an start to the voluntary PME. Since then the number of couples undergoing PME has dropped drastically nationwide, in spite of the policy of free of charge in some provinces. PME is a circumscribed preventive action on individual level, namely participation in a special screening test. The Health Belief Model(HBM) and the Theory of Reasoned Action(TRA) were among the most widely used individual-level theories in the literature for studying participation in medical screening.This paper developed a new model representing the synthesis of two models as the theoretic framework for an investigation of the factors affecting participation PME. Instrument development was approached by content and construct validity test. Multiple logistic multilevel analysis and Structural equation modeling(SEM) were the main statistical method. Data were collected from the self-designed instrument to2572newly married respondents, selected by a stratified randomized sampling at Marriage Registration Office in12counties in Zhejiang Province. The initial sample included148respondents for the item test of the instrument and598respondents for the instrument validity and reliability test. After a598sample pretest,the new model was evaluated with2572respondents using SEM. Cross validation was applied within two groups of Marlowe—Crowne Social Desirability Scale(MCSDS) with a cut-point7using SEM.The mail results were from people whose MCSDC froml to6(n=777).Here are the main results of this paper.1.The relationship between intention and action. Of those who intended to receive PME,75%eventually received it, While19.4%of them didn’t do. Those, who didn’t intent to participate and actually didn’t accept the PME, accounted for2.6%among the2572respondents. The SEM revealed that earlier intention to PME was vigorously correlated to their actual participation in PME(r=0.75, p<0.01).2.The correlation from attitude,subjective norm and perceived threat to earlier intention to PME. The SEM revealed that the correlation from attitude to intention is0.48(T=8.81, p<0.01).The total correlation from subjective norm to intention to PME was0.36including the direct path(r=0.22, p<0.01) and the indirect path(r=0.14, p<0.01).The correlation from perceived threat to intention was0.08minus.3.The correlation from perceived benefits and perceived barriers to attitude of PME. The standard correlation effect was-0.16(T=4.45, p<0.01) from perceived barriers to intention and0.52(T=11.98, p<0.01) from perceived benefits to attitude.4. The spurious association from perceived benefits to action of PME. The SEM revealed that perceived benefits was not correlated with action of statistically significance(r=-0.02, p=0.284). the spurious direct path(r=-0.16, p<0.01) was confounded by the social desirability.5. The correlation from perceived susceptibility and perceived seriousness to perceived threat. The standard correlation effect was0.89(T=37.74, p<0.01) from perceived susceptibility to perceived threat and0.52(T=33.59, p<0.01) from perceived seriousness to perceived threat.6. The correlation from normative belief and motivation to comply to subjective norm. The SEM revealed that the standard correlation effect was0.64 (T=30.59, p<0.01) from normative belief to subjective norm, and0.46(T=28.08, p<0.01) from motivation to comply to subjective norm.7. Influence from geographical environment to action. Multiple logistic multilevel analysis revealed that premarital medical examination behavior showed a clustering trait on the county level(P=0.018)and variance partition coefficient (VPC) of each variables was15.40%to17.58%.8. The role of external variable, such as demographic variables, in influencing behavior. There was no statistical significance in PME rates among different respondents of gender, age, Household Register, education, income, health insurance and history of premarital medical examination, despite the significant correlation with occupation. The PME rate of the respondents who haven’t attended medical examination during the last six moths was1.31times (95%confidence intervals,1.05-1.65) than those who have attended. OR(Odds ratio) was1.51(95%CI:1.14-2.00) for the firstly-married pregnant respondents and0.35(95%CI:0.23-0.51) for remarried respondents, compared with firstly-married unpregnant ones.It was concluded that the influence of attitude, subjective norm and perceived threats on PME were mediated through their effect on behavioral intention. Geographical environment explained16%of the variance in PME acceptance. Occupation, medical examination history during the last6months and type of marriage registration were influential to PME acceptance, while gender, age, Household Register, education, income, health insurance and history of premarital medical examination were not.As for the suggestion to PME acceptance in order of priority, this paper proposed that social norm and key figure’s recommendation such as physician, family members, head of the village women’s federation was an effective means to promote PME acceptance. Recommended strategies reducing perceived barriers, such as efforts to make PME as convenient as possible, free policy, process optimization, informed consent and privacy, may be quite effective in increasing couples’motivations to attend PME. Providing information about the benefits of PME will probably not be useful for recruiting couples, promotion should be based upon individualized and classified guidance such as different occupation, medical examination history.更多还原