【作者】 陈仁友；

【导师】 尹爱田；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2012， 博士

【摘要】 研究背景随着我国经济水平的快速发展,人口老龄化及疾病模式的转变,慢性非传染性疾病(以下简称慢病)已经成为我国城乡居民健康的主要威胁。慢病不断上升的趋势,导致健康损失、伤残显著增加,健康不公平和社会疾病负担日益严重,遏制慢病造成的严重危害已经成为政府高度关注的问题。如何控制慢病,西方发达国家曾采用高科技手段,结果耗费了巨额资金,并没有取得理想效果。此后,对于慢病的控制逐渐由治疗向预防,由针对高危人群向全人群转变。随着对慢病病因链概念的认识,慢病的发生不仅与靠近病因链近端危险因素(如高血压、高血糖、肥胖超重)和中间危险因素(如不健康饮食、缺乏体力活动、过度饮酒)有联系,更重要与病因链远端的社会因素、经济因素、文化因素、环境因素等社会决定因素有关联。当前,全人群策略主要是通过改变中间危险因素来达到对慢病的控制,忽略了病因链的远端危险因素对慢病的影响。因此,慢病控制有必要从其产生的根源上着手,同时作用中间危险因素和远端社会决定因素,才能达到有效控制慢病目的。健康促进策略是控制慢病最有效的策略。健康促进针对两类健康决定因素采取行动：一类是个人无法立即控制的健康决定因素,包括社会、经济和环境条件；另一类是个人能够控制的健康决定因素,包括个人健康行为,这两类健康决定因素与慢病的中间危险因素和远端的社会决定因素一一对应。英国、美国、芬兰等国家的研究证明,运用健康促进控制慢病的危险因素和社会决定因素,慢病控制取得了显著成效。我国慢病控制也提出了全人群策略、高危人群策略、健康促进策略、社区防治策略等综合性策略,并进行了试点,取得了一些有益的经验,但是在实际工作中,慢病防控策略实施的效果没有达到预期目的。一是我国慢病患病率居高不下。我国尽管在慢性病防控方面投入了大量的资源,但仍未很好地解决慢性病死亡率和患病率持续上升的问题。二是慢病危险因素尚未得到有效控制。《健康中国2020》公共卫生部分的战略研究结果显示,慢病控制危险因素流行基本处于失控状态。三是慢病公共政策制定缺失。某些政策制定者,特别是非卫生部门的政策制定者,并未充分意识到,烟草、营养、运动不足及减少有害使用酒精等相关公共政策在控制慢病行为和风险因素方面的作用。四是慢病支持性环境尚未建立。五是现实中把健康促进和健康教育等同看待,忽略了健康促进的政策制定和环境支持对于行为改变的重要作用。研究目的在系统分析国内外慢病控制经验基础上,根据健康促进理论,制定针对慢病危险因素以及社会决定因素的策略,通过在山东省农村地区的实证研究,评价健康促进策略控制慢病危险因素的可行性和有效性,探讨健康促进策略、居民知识、信念对居民慢病行为改变的中介路径,分析健康促进策略在个体层级和社区层级上对慢病行为改变的影响及其相互作用。研究方法论文采用了定量研究方法,根据社会经济发展水平和地理位置,采用多阶段分层抽样方法,选择山东省滕州市、沂源县和莒县3个样本地区。2010年10月进行干预前调查,共调查9个乡镇,16个村,调查对象为家庭内所有25岁以上的常住人口,有效调查1261人。2010年12月—2011年5月,对3个样本地区实施干预。2011年6月,对干预前调查对象进行了干预后效果评价调查,有效调查936人。调查内容包括两个部分：第一部分是家庭入户调查,主要调查居民的人口社会学特征、家庭经济状况、慢病知识、信念和行为改变等指标。第二部分是机构调查,调查样本地区县级疾控机构、乡镇卫生院以及村卫生室,共调查了3家县级疾控机构、9家乡镇卫生院、16家村卫生室,调查内容为当地卫生服务体系建设,社会经济发展指标,慢病控制资源、政策制定、环境支持、社区参与以及培训和督导等情况。数据采用MicrosoftAccess2003软件二次录入,SPSS16.0软件进行统计描述和统计分析,AMOS7.0软件进行健康促进策略、居民知识、信念对居民慢病行为改变的路径分析,HLMA7.0软件进行健康促进策略在个体层级和社区层级上对慢病行为改变的影响及其相互作用分析。研究结果(1)健康促进策略开展情况：在政策制定上,样本地区干预期间制定有关慢病规划、文件共38个；从制定文件的内容看,慢病防控综合规划、专病规划文件11个；慢病危险因素控制文件27个。在慢病防控经费上,2010年度滕州、沂源、莒县分别为18万元,10万元,6万元(未统计基本公共卫生服务工作慢病管理费用)。在健身环境上,样本地区都设立了农民体育活动中心。在社区参与方面,样本地区不同程度参加慢病计划制定和实施,参与慢病宣传教育活动,无烟场所和其他健康生活方式示范创建。在提高个人技能方面,县乡逐级开展了慢病培训；同时县乡村均开展了健康教育干预活动,针对高危人群和一般人群采取了不同干预措施。(2)健康促进策略对慢病知识改变的作用：干预后高血压的危险因素知晓率46.6%,干预前高血压的危险因素知晓率是27.1%；干预后糖尿病的危险因素知晓率是30.9%,干预前糖尿病的危险因素知晓率是24.1%。男性对于高血压和糖尿病的知晓率高于女性,年轻人知晓率要高于老年人,知晓率有随着年龄的增加而逐渐降低趋势。知晓率在不同性别之间和不同年龄之间,干预后均高于干预前,差值有统计学意义。(3)健康促进策略对慢病不健康行为信念的改变作用：戒烟信念方面,干预后认为吸烟对健康有害、在他人面前吸烟是不文明行为,烟瘾能够戒除的比例高于干预前。戒酒信念方面,干预后认为过度饮酒对健康有害、过度饮酒能够克服的比例高于干预前；在劝阻别人少量饮酒上,干预前后不存在差别。身体锻炼信念方面,干预后认为身体锻炼对健康有害、能够保持身体锻炼、希望得到医生锻炼的比例高于干预前。合理膳食信念方面,干预后认为饮食与健康有关、能够控制每天食盐量的比例高于干预前,干预前后在能够控制每天食油量方面的差别没有统计学意义。(4)健康促进策略对改变慢病不健康行为的作用：吸烟行为方面,干预后现在吸烟率为22.4%,干预前为25.6%,干预前后现在吸烟率的差别没有统计学意义；干预后男性平均每天吸烟量、戒烟率高于干预前；干预后戒烟的原因选择预防疾病的比例高于干预前。饮酒行为方面,干预后饮酒率为37.9%,干预前饮酒率为42.2%,干预前后饮酒率差别没有统计学意义；干预后戒(限)酒率、饮啤酒比例、每周饮酒次数高于干预前；干预后每次饮白酒量低于干预前；干预后戒(限)酒原因,选择预防疾病比例高于干预前。体育锻炼方面,干预后参加身体锻炼比例为16.3%,干预前参加身体锻炼比例为12.5%；干预前后的锻炼方式以走路为主；干预后每周1-3次锻炼的比例要高于干预前。合理膳食方面,干预后选择荤素均衡的比例为17.6%,高于干预前4.1个百分点；干预后嗜盐、嗜糖、嗜油的比例要低于干预前。(5)健康促进策略、居民知识、信念对居民慢病行为改变的中介路径分析：路径分析模型结果显示,年龄与行为改变呈负相关,即年龄越大,行为越难以改变,年龄每增加1个单位,行为改变下降0.07个单位。信念每增加1个单位,行为改变下降0.66个单位。行为改变最佳的路径是改变信念来实现对行为的改变,其次是知识,文化程度和人均年纯收入。分析研究对象人口社会学特征和知识、信念之间以及行为之间的效应,能够了解不同变量对慢病行为改变的作用大小,将有助于制定针对性的干预措施,提高慢病行为干预的效果。(6)健康促进策略在个体层次和社区层次上对慢病行为改变的影响及其相互作用：采用两层线性模型,分析和个体层级和社区层级对慢病危险因素的行为控制的影响,本研究第一层是干预对象,第二层是干预对象所在的社区(村)。因此,传统的线性回归模型是难以解决的。第一层随机回归模型结果显示,年龄、知识、信念对行为有影响。但是年龄对行为的影响在不同村之间变异不显著,所以年龄不纳入第二层模型；文化程度对行为改变的回归系数不显著,但该系数在不同村之间的方差显著,所以把文化程度纳入到第二层模型中。第二层随机回归模型结果显示,社区参与每增加1个单位,文化程度对行为改变的影响会增加0.0374个单位,即社区参与会强化文化程度对行为改变的作用；社区参与每增加1个单位,慢病知识得分对行为改变的影响会增加0.087个单位,即社区参与会强化知识得分对行为改变的作用；环境支持每增加1个单位,信念对行为改变影响会增加0.041个单位,即环境支持会提升信念对行为改变的作用；提高健康技能每增加1个单位,信念对行为改变影响会增加0.078个单位,即提高健康技能会提升信念对行为改变的作用。两层线性模型结果显示,社区参与、环境支持和提高个人技能对于居民个人行为改变均发挥了作用。结论与政策建议山东省农村居民吸烟、过度饮酒、身体锻炼不足、膳食不合理等的慢病危险因素流行水平较高,开展慢病危险因素控制研究,预防和延缓慢病的发生,降低慢病危险因素的发生率已成为迫切需要解决的问题。本研究围绕健康促进的政策制定、环境支持、社区参与、个人技能等方面,制定针对慢病四种危险因素的干预措施,通过样本地区干预前后的效果比较,结果显示,健康促进策略得到较好的执行,干预对象慢病危险因素的行为干预均有不同程度的改善,健康促进策略、知识、信念对慢病行为改变的中介路径分析已经明确,健康促进策略在不同层次上对慢病行为改变的影响及其相互作用已经解决。总之,健康促进策略是以科学的理论为指导、以慢病病因链的概念为基础、以控制慢病可以改变的行为方式和社会决定因素为目的,经济有效的一种干预模式。研究也发现,健康促进策略在实践中需要不断完善,控制效果还需进一步强化,因此,为进一步提高健康促进策略控制慢病危险因素的行为干预效果,结合健康促进策略、知识、信念对慢病行为改变的中介路径分析以及健康促进策略在不同层次上对慢病行为改变的影响,我们提出以下政策建议：慢病健康促进策略应引进一步引起全社会的共识；慢病健康促进活动应有明确的政策保障；进一步加强慢病控制“关口前移”的措施；进一步强化农村基层卫生组织“公共卫生服务功能”的建设；进一步提高农村居民参与慢病控制力度。更多还原

【Abstract】 Study backgroundWith rapid socioeconomic development, population aging and disease model change, non-communicable chronic disease (NCD) has become the main health threat to rural and urban residents. The continuous increase of NCD patients leads to the escalation of health loss and disability caused by NCD, which aggravates the health inequity and social disease burden, therefore, the government has pay more attention to NCD control. Many high-technologies are applied to control NCD in developed countries, however, the cost is high, and the result is not as expected. Then, some people think high risk population control is economic efficient, and the perspective is changed from therapy to prevention, but the result is disappointing. In the end, the control strategy is changed to whole population control. Result of studies on NCD pathogenesis chain shows that proximal risk factors (e.g., hypertension, hyperglycemia, obesity and overweight) and intermediate risk factors (e.g., unhealthy diets, lack of activities and excessive drinking) are correlated with NCD incidence, however, the correlation of distal risk factors, such as social, economic, cultural and environmental factors, is higher. Now, the whole population strategy is to control the intermediate risk factors, and distal risk factors are neglected. Hence, we should control the proximal risk factors to control NCD, and at the same time, intermediate and distal risk factors should be controlled too.Health promotion strategy is the most efficient NCD control strategy, whose intervene points are two types of health determinant factors:one includes social, economic and environmental factors; and the other includes personal healthy behavior. The evidences from UK, USA and Finland show that interventions on social determinant factors are efficient for NCD control. China has designed a comprehensive strategy, which includes whole population strategy, high risk population strategy, health promotion strategy, community prevention strategy, which obtains some experiences, however, the effect is no as expected. First, the NCD morbidity keeps at a high level. Although we input so much to control NCD, the morbidity and mortality of NCD is still high. Second, the NCD risk factors are not controlled efficiently. The study result of public health strategic group of <Healthy China2020> shows that China loses control of NCD risk factors. Third, NCD public policies are lacked. Some policymakers, especially non-health department’s policymakers, don not realize the function of tobacco, nutrition, activities and alcohol related public policies in NCD control. Fourth, supportive environment of NCD control is lacked. In addition, the form and content of health promotion need to be improved.Study objectiveFirst, we summarize national and international NCD control experiences; then, based on health promotion theory, we design a health promotion intervention model targeted on NCD risk factors and social determinant factors; third, we implement this intervention in rural areas of Shandong province. In this study, we investigate how health promotion strategy is implemented, evaluate the intervention impact, analyze the pathway between health promotion and NCD risk factors, discuss the effect factors of NCD control, in the end, we make policy recommendation on how to control NCD risk factors through health promotion.Study MethodsSampling:According to socioeconomic and geographic status, three counties are selected:Tengzhou, Yiyuan, Ju county. Multi-stage stratified method is used to select intervention population. Three towns are selected from each county, two villages are selected from each town, and the survey population should be permanent residents more than25. On October,2010, we collect baseline information, in total,1261residents are surveyed. On June,2011, we collect impact information, in total,936residents are surveyed.Tools:One is household survey, the main content of which is demographic and economic status, personal living styles, health related knowledge and so on. The other is facility survey, the object of which is county CDC, township health centers and village clinics. The content includes local health system situation, socioeconomic index, resources and policies of NCD control, community participation, training, supervision and so on. Data entry and analysis:MicrosoftAccess2003is used to data entry, SPSS16.0is used to descriptive analysis, AMOS7.0is used to analysis the pathway of intervention impact, and HLM7.0is used to analyze the effect factors of intervention impact.Study results(1) situation of health promotion strategy implementation:In total, there are38documents about NCD control, which includes11comprehensive and special plans,27NCD risk factors control documents. In2010, the NCD control funds (without basic public health service funds) of Tengzhou, Yiyuan, and Ju county are180,000,100,000, and60,000respectively. There is a large difference among three counties. All the three countries build rural residents’ sports activities centers. In pilot areas, there is different level participation of communities in the field of NCD plan design, health education, smoking-free environment building and other healthy living styles activities. In pilot areas, county hospitals and township health centers provide personal NCD control ability training. Three tiers health facilities provide different health education service to high risk population and general population.(2) The impact of health promotion strategy to residents’NCD related knowledge:the intervention, the rate of knowing hypertension risk factors among target population increases from27.1%to46.6%; the rate of knowing diabetes risk factors among target population increases from24.1%to30.9%; the rate is higher among men compared with women, and the same situation among young men compared with the olds, the rate decreases with the age increases. The rate of different sexes and age groups all increases after the intervention, the differences have statistical meaning.(3) The impact of health promotion strategy to residents’unhealthy attitudes:About attitudes towards smoking cessation, the rate of people who thinks smoking is harmful, smoking in public is impolite, smoking habit can be stopped increases after intervention; About attitudes towards drinking cessation, the rate of people who thinks excessive drinking is harmful, excessive drinking habit can be stopped increases after intervention, however, the rate of persuading others to drink little does not change after the intervention. About attitudes towards physical activities, the rate of people who thinks physical activity is good to health, who can keep exercising, and who wants to get advice from doctor’s increases after intervention. About attitudes towards healthy diet, the rate of people who thinks diets has correlation with health, which can control the salt intake, increases after the intervention; however, the rate of people who can control oil intake every day does not change after the intervention.(4) The impact of health promotion strategy to residents’ unhealthy behavior:The smoking rate decreases from25.6%to22.4%after the intervention, however, the difference has no statistical meaning; after intervention, the cigarettes number and smoking cessation rate among men increase. The drinking rate decreases from42.2%to37.9%after the intervention, however, the difference has no statistical meaning; after intervention, drinking cessation/limit rate, the rate of people who drink beer, and the drinking frequency every week increase, however, the wine volume drinking every time decreases. More people who stop or limit drinking for the reason of disease prevention. The physical activities rate increases from12.5%to16.3%after the intervention, and walking is the main form of activity; rate of people who do exercises1to3times every week is higher after intervention. The healthy diet rate increases from13.5%to17.6%after the intervention, and the rate of people who eat more salt, sugar and oil is lower after intervention.(5) The pathway analysis of health promotion strategy intervention impact: Pathway analysis model is applied to analyze the impact between demographic status, knowledge, attitude and behavior. The result shows that the older, the behavior change is harder, OR value is-0.007. Attitude is the most important variable to behavior change, OR value is-0.66. The effect level of knowledge and education degree is intermediate. The least effect factor is annual income per capita. Through standardized coefficient of pathway analysis, we can find the most efficient measure to change behavior, implement targeted risk factors intervention, and improve the impact of NCD behavior intervention.(6) The effect factors analysis of health promotion strategy intervention impact:Personal variables are nested in social variables, so traditional linear regression model can not be used. In our study, two levels multilayer linear model is used to analyze the impact of social variables and personal variables to NCD risk factors control. In our model, the first level is intervention objects; the second level is villages where the objects live, the characteristics of county and town are added into village to estimate the effect and direction. The first level random regression model result shows, age, knowledge, and attitude can affect the behavior, however, the effect of age has no difference among different villages; the effect of education has no statistical meaning, however, it has statistical meaning among different villages, hence, education is added into the second level model. The second level random regression model result shows, community participation will reinforce the effect of education to behavior change, and OR value of education is0.0374; community participation will reinforce the effect of NCD knowledge score to behavior change, and OR value of education is0.087; supportive environment will reinforce the effect of attitude to behavior change, and OR value of education is0.041; improving health skills will reinforce the effect of attitude to behavior change, and OR value of education is0.078.Conclusion and Policy recommendationsThe incidence of NCD risk factors is high relatively in rural areas of Shandong province, such as smoking, excessive drinking, lack of physical activities, and unhealthy diet. It is imperative to study how to control these risk factors to decrease the incidence of NCD. In this study, we design four types of NCD risk factors intervention from perspective of policy making, environment support, and community participation, personal health skill based on health promotion. Through impact evaluation before and after the intervention in pilot areas, we find that health promotion control strategy is implemented well relatively, risk factors are improved, and health promotion intervention impact pathway and effect factors are identified. The result shows health promotion is an economic efficient intervention model to prevent NCD risk factors. It focuses on intermediate and distal part of pathogenesis chain through changing unhealthy behavior and social determinants based on scientific theory.We also find that health promotion and intervention should be improved in practice, and impact should be reinforced, hence, to improve the impact of NCD risk factors control, we make policy recommendations as follows: NCD health promotion strategy should arouse common view of the whole society; NCD health promotion activities should be guaranteed by definite policies; prevention of NCD should be paid more attention; public health service function should be reinforced in rural basic level health facilities; rural residents’ participation should be improved.更多还原