【作者】 许辉；

【导师】 方鹏骞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 目的：当前，湖北省不少中小企业职业卫生工作存在问题多，员工职业卫生服务状况差。加强湖北省中小企业员工基本职业卫生服务的研究，促进职业卫生服务的可及性，扩大职业卫生服务的覆盖面，对于推进湖北省中小企业职业病防治工作的开展、保障中小企业员工的职业健康权益具有十分重要的现实意义。方法：1文献情报分析查阅收集国内外有关基本职业卫生服务、卫生服务可及性、中小企业职业病防治等方面的研究成果和其他信息资料，为构建基本职业卫生服务可及性研究的概念模型和探究湖北省城市中小企业员工基本职业卫生服务的可及性路径提供基础。2现场调查在武汉市、黄石市、荆门市、随州市等4个典型调查地区，采用问卷调查、知情人半结构访谈、二级资料收集等方法，通过员工、中小企业、职业卫生服务机构、政府监管部门等4个相关方，从4个维度对基本职业卫生服务的可及性进行现场调查。3资料分析方法3.1统计学分析运用SPSS11.5软件采用χ2检验或非参数检验、非条件logistic回归、多元线性回归、Spearman等级相关、系统聚类等方法对数据资料进行分析。3.2综合评价分析运用DPS V7.05对4个地区的城区中小企业员工职业健康监护可及性进行TOPSIS分析，探讨可及性在地区间的差异对其城区中小企业员工职业健康监护状况的影响。3.3PEST分析从政治、经济、社会、技术等4个方面，探讨外部环境因素对湖北省城市中小企业员工基本职业卫生服务发展的积极和消极影响。3.4宏观政策规范分析从可及性视角对湖北省城市中小企业员工基本职业卫生服务现存的关键问题及其根源和作用机制进行分析，继而系统提出湖北省城市中小企业员工基本职业卫生服务发展的模式与策略建议。结果和结论：1.中小企业员工的基本职业卫生服务状况不容乐观，在当前务工企业5项基本职业卫生服务均享有的员工占29.8%。Logistic回归分析结果显示，影响该群体基本职业卫生服务状况的因素有是否参加工伤保险、是否与所在企业签订劳动合同、所在企业规模、是否加入工会组织、月收入、周工作时间、年龄组、所在工作岗位性质等。2.中小企业员工劳动合同签订情况尚可，参加工伤保险和加入工会组织情况较差；职业健康监护知识水平欠佳，职业健康监护意愿较强，但对职业健康监护的重视依然不够；健康信念需要进一步强化。Spearman等级相关分析结果显示，该群体的职业健康监护意愿得分与知识得分间存在正相关关系（r=0.467,P<0.05）。3.中小企业及其负责人职业卫生工作意识依然不强，未能切实担负起主体责任。职业卫生管理基础工作开展情况较差，管理人员配备数量少，相关工作能力和经验缺乏，学习培训不够，职业卫生管理制度尚待规范，职业卫生档案建立情况不好；基本职业卫生服务经费投入情况较差，职业健康检查等经费难以得到保证。根据指标聚类（R型聚类）筛选出的代表指标，对80家中小企业进行样本聚类（Q型聚类）的结果显示，集体企业、私营企业的职业卫生管理基础工作和经费投入情况相对较差。4.职业卫生服务机构的建设在近几年取得了较大的进步，大部分地区职业健康检查机构的体检能力在总量上能够基本满足本地区接触职业病危害因素劳动者进行职业健康检查的需要。但职业健康检查机构数量仍偏少，布局不够合理，中小企业员工难以在较近距离内方便、及时获得机构提供的体检等服务；“检查服务方式”、“健康检查质量”等是职业健康检查机构应重点加以改进的方面。基层医疗卫生机构通过基本公共卫生服务项目，在中小企业员工中开展职业卫生健康教育和咨询指导等服务的成效尚未得到明显体现。5.许多地区政府尚未制定职业病防治规划，安监部门尤其是基层地区安监部门在职业卫生监管专门机构、专职人员、执法装备、工作经费等方面尚未得到很好保证，职业病防治的多部门监管协作机制尚未建立，监督管理力量依然较为薄弱，对企业尤其是中小企业的监督检查覆盖不够，但监督执法和违法处罚力度有所加大，对职业健康检查机构的监督管理状况尚可。6. TOPSIS法综合评价结果显示，4个地区员工职业健康监护可及性指标值排序与其职业健康监护状况指标值排序具有较好的对应关系，表明可及性的各维度和指标能较好代表潜在促进和阻碍服务对象获得基本职业卫生服务的各种主要因素。7.模式与策略建议湖北省城市中小企业员工基本职业卫生服务要构建“政策性扶持、市场化运作、多方位监管”的发展模式。湖北省城市中小企业员工基本职业卫生服务发展的策略建议：（1）加强组织领导，完善中小企业员工基本职业卫生服务的政策措施和法规标准。（2）加强宣传教育培训，提高对基本职业卫生服务的认识。（3）强化中小企业主体责任，保障员工获得基本职业卫生服务的正当权利。（4）加强职业卫生服务网络和能力建设，满足中小企业员工基本职业卫生服务的需要。（5）探索多渠道筹集机制，建立中小企业员工基本职业卫生服务的经费保障。（6）理顺职业卫生监管体制和运行机制，形成对中小企业监督管理的合力。（7）加强职业卫生人才队伍建设，推动相关工作能力水平的提升。（8）发挥工会组织等其他监督力量的积极作用，促使中小企业切实保障员工的职业健康权益。创新点：1.在“人人享有基本医疗卫生服务”的背景下，基本职业卫生服务将是今后较长一个时期内开展中小企业员工职业病防治工作的重要思路。湖北省对中小企业员工基本职业卫生服务的研究尚处于空白状态，本研究提出了湖北省城市中小企业员工基本职业卫生服务发展的模式与策略建议。2.可及性是影响卫生服务利用的主要因素之一，是理解卫生政策、制定卫生政策的关键。本研究将卫生服务可及性的概念运用到职业卫生服务领域中，构建基本职业卫生服务可及性概念模型，对中小企业员工基本职业卫生服务的可及性进行系统研究，具有一定的创新性。更多还原

【Abstract】 Objective:At present, there exists many occupational health problems in SMEs (small andmedium-sized enterprises) in Hubei Province, and workers’ occupational health service isin poor conditions. In order to promote prevention and cure of occupational diseases and toprotect SME workers’ occupational health interests, it is of great practical significance tocarry on further research on SME workers’ basic occupational health service in Hubei,promote the accessibility and expand the coverage of occupational health service.Methods:1Literature analysisRead and collect the main research results home and abroad on basic occupational healthservice, accessibility of health service, SME workers’ occupational disease prevention, toprovide a basis for the building of a conceptual model on basic occupational health serviceand the exploration of accessibility methods of SME workers’ basic occupational healthservice in Hubei.2On-site investigationQuestionnaires, insider semi-structured interviews and secondary data collection etc. wereemployed to implement on-site investigation of basic occupational health serviceaccessibility from four dimensions-workers, small and medium-sized enterprises,occupational health service institutions, government regulatory authorities in typical surveyregions including Wuhan City, Huangshi City, Jingmen City and Suizhou City.3Data analysis methods3.1Statistical analysisChi-square test or non-parametric test, non-conditional logistic regression, multiple linearregression, Spearman rank correlation, Hierarchical cluster and other data analysis methodswere employed by SPSS11.5software. P <0.05was considered statistically significant.3.2Synthetical evaluation analysisTOPSIS analysis of accessibility of SME workers’ occupational health surveillance in thedifferent regions was conducted using DPS V7.05, to explore the influence of inter-regional accessibility differences on SME workers’ occupational health surveillance.3.3PEST analysisFrom the political, economic, social and technical aspects, this paper discusses bothpositive and negative impacts that external environmental factors have on the developmentof SME workers’ basic occupational health service in Hubei.3.4Macroscopical policy normative analysisFrom the perspective of accessibility, the key problems and their causes and mechanisms ofSME workers’ basic occupational health service in Hubei were analyzed, and therecommendations for corresponding model and strategy about the development of SMEworkers’ basic occupational health service in Hubei were advanced systematicallyafterwards.Results and conclusions:1SME workers’ basic occupational health services situation is not optimistic. Only29.8%workers are entitled all the five basic occupational health service currently. Logisticregression analysis shows that the factors affecting their basic occupational health servicesare as following: whether to participate in work-related injury insurance, whether to signlabor contracts with their enterprises, size of enterprises, whether to join labour unions,their monthly income, weekly working time, age group, job nature.2SME workers’ labour contract-signing condition is satisfying; while work-related injuryinsurance and labour union-joining situation is poor. Knowledge of occupational healthsurveillance is poor; attention to occupational health surveillance is inadequate despite thestrong desire of occupational health surveillance. Health beliefs should be furtherstrengthened. Spearman rank correlation analysis shows that there is a positive correlationbetween score of desire and that of knowledge about occupational health surveillance（r=0.467,P<0.05）.3People in charge of SMEs are lack of awareness of occupational health, thus fail to takeon the main responsibility. Foundation work of occupational health management is in poorcondition, with a small number of management employees lacking of related work capacityand experience and enough training. The occupational health management system is notstandardized and occupational health archives establishment is unsatisfying. Investment in basic occupational health service is not enough thus occupational health examination feescan hardly be guaranteed. Based on a representative indicator selected via variables cluster(R type cluster), the analysis of cases clustering (Q type cluster) over80SMEs shows thatfoundation work of management and investment about occupational health in collective andprivate enterprises are in relatively poor condition.4Hubei Province has made great progresses in building occupational health serviceinstitutions in recent years. The occupational health examination supply in aggregate canbasically meet the occupational health examinations needs of workers exposed tooccupational hazards in most districts. However, the number of occupational healthexamination agencies are still less than normal and are not reasonably distributed, thusSME workers have difficulty in having timely and convenient access to healthexaminations and other service provided by the agency in relatively short distance.Occupational health examination institutions should focus on improving health servicemethods and its quality. The effectiveness of occupational health service education andcounseling on SME workers provided by primary health care institutions through basicpublic health service programs has not yet been evident.5The plan for occupational disease prevention has not been set up in many areas of HubeiProvince. Safety supervision departments, especially those in grassroots areas, have notbeen guaranteed specialized agencies, full-time staff, law enforcement equipment, andenough working expenses. Multi-sectoral supervision and coordination mechanism ofoccupational disease prevention has not yet been established. Supervision and managementforce still need strengthening. Supervision and inspection coverage of enterprises,especially SMEs, is not enough; while supervision, law enforcement and punishment havebeen improved and the supervision and management of occupational health examinationagencies is in fair condition.6Synthetical evaluation analysis via TOPSIS method shows that in the four regions, theorder of accessibility of workers’ occupational health surveillance has a fine correlationwith that of their occupational health surveillance state, meaning the dimensions andindicators of accessibility can better represent various main factors in helping or impedingobject acquire basic occupational health service. 7Recommendations for mode and strategyA developing mode with policy support, market-oriented operation and multi-facetedregulation should be built regarding urban SME workers’ basic occupational health servicein Hubei.The recommendations for strategy about the development of urban SME workers’ basicoccupational health service in Hubei:(1) Strengthen guidance of organizations, and revise policies and laws to improve SMEworkers’ basic occupational health service.(2) Strengthen publicity and training to enhance knowledge of basic occupational healthservice.(3) Increase SMEs’ responsibility for the protection of the legitimate rights of workers’access to basic occupational health service.(4) Build up occupational health service network and enhance its capacity to meet the needsof SME workers’ basic occupational health service.(5) Explore various channels to raise money to fund SME workers’ basic occupationalhealth service.(6) Make clear the occupational health regulatory system and operational mechanism toform a joint force of the supervision and management of SMEs.(7) Increase the number of professional occupational health personnel to promote theupgrading of working ability.(8) Make use of labour unions and other supervisory power to urge SMEs to effectivelyprotect workers’ occupational health interests.Innovations:1In the context of “Basic Health service for All”, basic occupational health service will be,for a fairly long time in the future, an important thought to SME workers’ occupationaldisease prevention and control. In Hubei, this research still being in a blank state, this studypresents the recommendations for mode and strategy about the development of urban SMEworkers’ basic occupational health service.2Accessibility is one of the main factors influencing the utilization of health services andthe key to the understanding and developing of health policy. In this study, innovatively, the concept of health service accessibility is put into practice to construct a conceptualmodel to conduct a systematic study on accessibility of SME workers’ basic occupationalhealth service.更多还原