【作者】 陈建伟；

【导师】 梁伟雄；

【作者基本信息】 广州中医药大学 ， 中医内科学， 2009， 博士

【摘要】 研究背景:近几年,对中医质疑声不断,中医学的生存发展似乎出现了危机。主要原因:①目前对中医学效果的评价只评价了中医药或针灸的“治疗”效果,没有考虑中医的整体效果;②评价中医的效果是采用了西医治疗常用的实验室检查标准—各种生理、生化检查的指标。③只是在生物-医学模式下考评中医的效果。中医的“整体观”,强调“天人合一,认为人是有机整体,人与自然是统一的。中医学整体观不仅讲用药物治疗疾病,还强调要运用预防、养生、康复、运动、饮食调养、心理调适等多种手段来维护人的健康。所以,对中医效果的评价不能止步于治疗的评价,而是要对中医所有整体措施产生的效果进行综合评价。这种综合评价是对人的健康的综合测量,应该包括心理、生理、社会适应等各方面。为此,我们用生存质量作为这一综合评价体系。目前能体现中医整体观的具体运用的就是“有中医药特色社区卫生工作”,评价中医社区的效果可反映中医整体效果。有中医药特色社区卫生工作中包括对中医知识的传播、中医预防、保健措施及适宜技术的推广以及中医相关饮食、养生干预,这和现代健康教育工作对健康知识的传播、培养采取健康行为的信念并最终形成某种健康行为是一致的,它实质上就是中医的健康教育工作。由此,我们借助现代健康教育“知信行”理论来研究有中医药特色社区开展工作后居民的中医“知信行”情况,并借助《SF-36生存质量量表》作为社区中医居民健康状况的综合测评指标,考评中医整体观的效果。通过分析具有不同的中医知识、不同的中医信念、是否在生活中采用中医的保健、养生方式的不同人群在生存质量方面的差异,来探讨中医的整体效果。研究目的:1.研制一份《中医知、信、行调查问卷》,用于测量社区居民中医知识的掌握程度、对中医的信念和态度、平时生活中运用中医预防、保健、康复、养生、饮食调养、健身方法的频率和习惯。2.运用《中医知、信、调查问卷》,调查了解荔湾区某国家中医药示范社区和某普通社区老年居民的中医知、信、行现状。3.运用《SF-36简明生存质量量表》调查了解两个社区老年居民生存质量情况。4.分析中医知信行与生存质量的关系。并为卫生机构进一步开展中医社区工作提供建议。研究方法:1.《中医知、信、行调查问卷》的研制运用德尔斐(Delphi)专家咨询法。经过两轮专家咨询,在综合考虑专家的积极系数、权威系数、集中系数和协调系数的基础上,筛选、确定《中医知、信、行调查问卷》的条目,对确定的问卷做信度、效度评价,最后确定《中医知、信、行调查问卷》。2.调查采用典型调查和整群随机抽样调查结合的方法。选取荔湾区获“国家有中医药特色示范社区”称号的华林街社区和普通社区金花街社区的各两个居委共400名老年居民参加调查。采用《中医知、信、调查问卷》和《SF-36简明生存质量量表》进行问卷调查。3.统计分析两个社区调查数据。比较两个社区《中医知、信、行调查问卷》总分得分情况和知、信、行三个部分的得分情况,探讨中医知、信、行与各影响因素的关系;比较两个社区《SF-36简明生存质量量表》的得分情况,探索生存质量与各影响因素的关系;分析《中医知、信、行调查问卷》得分与《SF-36简明生存质量量表》得分的关系,探讨中医社区工作进一步开展的方向。研究结果:1.经过30位专家两轮咨询,筛选、确定29个条目作为《中医知、信、行调查问卷》的最后条目。问卷经信度、效度检验,重测信度,前后两次调查结果的Spearman相关系数均大于0.5,且P值均小于0.01,问卷总体Cronbach’sα系数分别为0.921、0.955、0.901及0.963,均在0.90以上;分半信度分别为0.864、0.853、0.787及0.872,均在0.75以上。效度方面,专家对问卷的评价意见集中,取得专家一致认同,所以具有较好的内容效度;结构效度采用因子分析的方法,因子分析,产生了3个公因子,它们总共能解释总体方差的65.4%,且因子载荷值皆属中高程度(≥0.4),表明其结构效度较好。问卷的信度、效度均达到了要求。2.《中医知、信、行调查问卷》的调查结果显示:中医社区老年居民对中医知识的掌握的正确率、对中医的信念和信心、平时生活中运用中医的保健方法及采用中医治疗的人数普遍高于普通社区的老年居民。中医知、信、行三方面是互相影响的,均具有直线相关关系。进一步探讨各影响因素对中医知、信、行的影响,经Logistic回归分析发现:中医知信行总分方面,中医社区的高于平均值的OR值是普通社区的15.27倍,女性是男性3.31倍,收入在2—5千元的居民中医知信行总分较高;分别对各影响因素与中医知、信、行三部分做Logistic回归分析显示:中医社区、中低收入人群(1千元以下、1—2千元、2—5千元)、在荔湾区居住时间超过10年和年龄在60～70岁的居民《中医知、信、行调查问卷》“知”得分较高;中医社区老年居民对中医的信念、态度和日常采取中医有关的行为方面比普通社区要好(中医社区的中医“信”部分得分高于平均值的OR值是普通社区的20.77倍;中医社区的中医“行”部分得分高于平均值的OR值是普通社区的3.29倍)。3.《SF-36简明生存质量量表》的调查结果显示:中医社区老年居民的生存质量在SF-36生存质量的生理职能、总体健康、活力、情感职能、躯体疼痛五个维度得分高于普通社区,总的生存质量得分也高于普通社区。经Logistic回归分析显示:生理功能得分中医社区、老年女性、本科学历的人群要高;中医社区还是生理职能得分、情感职能得分、躯体疼痛得分的影响因素,均比普通社区的OR值要高。可能是由于中医的老年居民由于更多受到中医文化的影响,掌握了一定的中医调适心理的方法,并且由于在生活中更多地练习中医健身术如太极拳、太极剑、气功等,所以情感问题相对较少,身体受到疼痛的影响也比普通社区要少。4.《中医知、信、行调查问卷》得分与《SF-36生存质量量表》各维度得分关系的统计分析显示:生存质量八个维度中生理职能、总体健康、活力、社会功能、精神健康、躯体疼痛六个维度得分与“知信行”总分呈直线相关;生存质量总分与《中医知、信、行调查问卷》“知”、“信”、“行”三部分分别做Pearson相关分析,显示生存质量总分与中医知、信、行均存在一定的正相关性。典型相关分析显示:“信”得分、“行”得分越高,生存质量各项得分也越高。进一步分析显示:中医的信念部分得分越高的人群,其生存质量中的生理职能、社会功能、精神健康、躯体疼痛得分越高,提示越是愿意接受中医药治疗,其躯体疼痛得分越高(逆向计分,表明躯体疼痛程度越轻),从而其生存质量越好。在行为方面,较多采用中医的健康行为、运用中医保健等方法的人,其生存质量中生理机能、精力、社会功能、精神健康、躯体疼痛得分就会越高。结论:1.《中医知、信、行调查问卷》经德尔斐专家咨询法筛选、确定条目,并经信度、效度评价,达到要求,可以作为测评社区居民中医知识、信念和行为调查的工具并在今后的工作运用推广。2.采用的中医整体观模式开展工作的社区-“有中医药特色社区”老年居民中医知识掌握程度要高过普通社区,对中医更有信心、更愿意接受中医的治疗、保健、康复、养生、饮食调养、健身等措施、方法,在生活中,中医社区的老年居民比普通社区的老年居民更经常使用中医的保健方法、饮食调养方法、更多地接受中医的治疗手段,并经常练习中医健身术、自行采纳中医心理调适的方法。也反映了“有中医药特色”社区的中医推广工作,对居民中医知识、信念和态度的影响要超过普通社区,说明了工作的力度和成效。3.中医社区老年居民《SF-36简明生存质量量表》的总分和生理职能、总体健康、活力、情感职能、躯体疼痛五个维度得分高于普通社区,反映以生存质量作为结局评价指标,中医社区的老年居民健康状况比普通社区要好。也反映了中医整体观的具体运用使老年居民的生存质量在一定程度上好过普通社区,证明中医整体观的运用效果是肯定的,对生存质量的影响是正面和积极的。4.《中医知、信、行调查问卷》得分与《SF-36简明生存质量量表》得分的关系的统计分析显示:中医社区作为影响因素对生存质量总分和生理功能、生理职能、情感职能、躯体疼痛等维度得分存在积极影响,也即能提高总体生存质量、改善生理功能、生理职能、情感职能和躯体疼痛等方面。5.横断面研究的缺陷和不足是它对因果关系推断的论证力比较弱,所以,进一步开展研究,如果能够采用随机对照或前瞻性队列研究的方法,采取更规范和量化的中医工作指标进行干预设计,并对干预因素加以控制,最后比较中医和非中医社区居民的生存质量,结果会更有说服力。更多还原

【Abstract】 Backgrounds:In recent years,traditional Chinese medicine(TCM) has been constantly challenged,and it seems that the existence and development of TCM appear crisis.The main reasons includes:①The current evaluation of TCM effect only covers the therapeutic function of Chinese medicine or acupuncture, without considering the entire effect of TCM;②The evaluation of TCM effect applied the laboratory examination standards that western medicine often used in treatment,various kinds of physiological and biological indexes;③TCM effect was just evaluated under the biological medical model.The holistic concept of TCM emphasizes the harmony between man and universe,which believes that human being is an organic whole,man and the nature are unified.The holistic concept not only remarks on using medicine to deat with diseases, but also places emphasis on applying prevention,health cultivation, rehabilitation,exercise,dietary care and psychological adjustment to protect the health of people.Therefore,the evaluation of TCM effect should not stopped at the estimation of treatment,while synthetic evaluation should be performed on the effect of the overall measures of TCM.This kind of synthetic evaluation is the integrated measurement of human body’ s health, which should consist of the aspects of psychology,physiology and social accommodation.For this reason,we take quality of life as the synthetic evaluation system.Nowadays,the specific apptication that could indicate the hotistic concept of TCM is the community health work with TCM characteristics, and the evaluation of the effect of TCM community is able to reflect the overall function of TCM.Community health work with TCM characteristics includes the dissemination of TCM knowledge,TCM prevention,health care measures and spread of appropriate techniques,as well as TCM related diet and health cultivation intervention,and all of these are in accordance with the dissemination of health knowledge by modern health education,cultivation of the faith of performing health behaviors,and the formation of a certain health behavior in the end.It is virtually the health education of TCM.With the theory of knowledge,attitude and practice(KAP) in modern health education, we studied the citizen condition of the knowledge,attitude and practice about TCM(TCM KAP) after the work of the community with TCM characteristics carries out,and SF-36 questionnaire of the quality of life was taken as the synthetic evaluation indexes for the health condition of community citizens,so as to estimate the effect of the holistic concept of TCM.The overall effect of TCM was discussed by analyzing the differences of quality of life among different crowds,on the aspects of various TCM knowledge,different TCM faith,whether use TCM health care and cultivation in daily life.Objective:1.An investigation questionnaire of TCM KAP was developed to measure community citizen the grasping extent in TCM knowledge,the faith and attitude to TCM, the frequency and habit of using TCM prevention,health care,rehabilitation, health cultivation,dietary care and body building method in daily life.2.The investigation questionnaire of TCM KAP was applied to investigate elder citizen’ s situation of knowledge,attitude and practice about TCM in a certain national TCM model community of Liwan district and some ordinary community.3.The situation of the quality of life about the elder citizens in these two communities was investigated by SF-36 simple quality of life scale.4.The relation between TCM KAP and quality of life was analyzed,and suggestions were proposed for the sanitary institutions to further carry out TCM community work.Methods:1.The development of the investigation questionnaire of TCM KAP uses Delphi expert consultant method.After two series of expert consultation,on the basis of synthetically considering the expert’ s positive coefficient,authority coefficient,concentration extent and coordination coefficient,the items of the investigation questionnaire of TCM KAP was screened and determined, reliability and validity evaluation of the definite questionnaire was performed,and the investigation questionnaire of TCM KAP was finally determined.2.The investigation applied the methods of typical survey and cluster random sampling survey.About 400 elder citizens in Hualin street community-National Model Community with TCM Characteristics in Liwan district,and an ordinary community-Jinhua street community were selected to participate the investigation.They were investigated by the investigation questionnaire of TCM KAP and SF-36 simple quality of life scale.3.The data of these two communities were statistically analyzed.With the comparison of the total scores of the investigation questionnaire of TCM KAP and the scores of knowledge,attitude and practice respectively between the two communities,the relation between TCM KAP and each influencing factor was discussed.The relation between quality of life and each influencing factor was explored by comparing the score conditions of SF-36 simple quality of life scale in the two communities.The relation between the score of the investigation questionnaire of TCM KAP and that of SF-36 simple quality of life scale was analyzed to discuss the further direction of TCM community work.Results:1.After two series of consultation with 30 experts,about 29 items were screened and determined as the final items of the investigation questionnaire of TCM KAP.After reliability and validity test,retest of reliability of the questionnaire,the Spearman correlation coefficient of the results of the two investigation were both bigger than 0.5,and the value of P is smaller than 0.01.The total Cronbach’ s a coefficients of the questionnaire are 0.921, 0.955,0.901 and 0.963 respectively,and the mean is over 0.90.The split-half reliabilities are 0.864,0.853,0.787 and 0.872 respectively,and the mean is over 0.75.On the aspect of validity,the evaluation opinions of experts on the questionnaire were concentrated,which got the uniform agreement from the experts,so it has better content validity.Structure validity used the method of factor analysis,3 common factors were produced by factor analysis, all of which could explain 65.4%of the population variance,and all the factor loading values belonged to the middle and high extent(≥0.4),and it indicates the structure validity is good.Both the reliability and validity of the questionnaire reach the requirement.2.The results of the investigation questionnaire of TCM KAP indicated that the correct rate of grasping TCM knowledge,faith and confidence on TCM,number of people using TCM health care methods and treatments in daily life of the elder citizens in TCM community were higher than those in the ordinary community.The three aspects of knowledge,attitude and practice of TCM are mutually affected,and all of them have the relation of linear correlation. The influences of various factors on the TCM KAP were further discussed,after Logistic regression analysis,it was found out that,on the aspect of the total score of TCM KAP,the OR value that higher than the mean in TCM community was 15.27 times of that of the ordinary community,female was 3.31 times of male, and the total score of the TCM KAP among citizens with 2 to 5 thousand income is higher.The Logistic regression analysis of all the influencing factors and knowledge,attitude and practice of TCM indicated that the people in TCM community with middle to low income(below 1 thousand yuan,1-2 thousand yuan, 2-5 thousand yuan),more than 10 years of habitation in Liwan district,and age from 60 to 70,the score of knowledge was higher.The elder citizens in TCM community are better than the ordinary community on the aspects of faith and attitude to TCM,TCM related behaviors in daily life(The OR value of the attitude part that is over the mean in TCM community is 20.77 times of that of the ordinary community,and the OR value of the practice part that is over the mean in TCM community is 3.29 times of that of the ordinary community.)3.The results of SF-36 simple quality of life scale showed that the quality of life score of the elder citizens in TCM community was higher than that of the ordinary community on the aspects of physiological functional authority, overall health,energy,feeling function and body pain,the total score of the quality of life was also higher than that of the ordinary community.The Logistic regression analysis indicated that the score of people in TCM community,elder females,with undergraduate degree,is higher.TCM is also the influencing factor to the score of physiological functional authority, feeling function and body pain,whose OR values are higher than those in the ordinary community.Maybe it is due to the reason that the elders in TCM community accepted more effects from TCM cultures,grasped some methods of TCM to adjust their psychology,as well as practice body buildings more frequently in daily life,such as Tai Ji Quan,Tai Ji Jian,Qi Gong,etc,their feeling problems were relatively less,and the effect of pain to the body was little,comparing with the ordinary community.4.The statistical analysis of the relation between the score of the investigation questionnaire of knowledge,attitude and practice about TCM and each score of SF-36 quality of life scale indicated that,among the eight dimensions in quality of life,the scores of physiological functional authority,overall health,energy,social function,emotional health and body pain have linear correlation with the total score of knowledge,attitude and practice.The total score of quality of life and each part of knowledge, attitude and practice in the investigation questionnaire of TCM RAP were performed the relative analysis of Pearson respectively,which showed that the total score of quality of life has positive correlations with knowledge, attitude and practice about TCM respectively.The typical correlation analysis manifested that the higher score of attitude and practice,the higher score of each item in quality of life.Further analysis indicated that the people with higher score of attitude about TCM,the higher score of physiological functional authority,social function,emotional health and body pain in quality of life,which could be drew to the conclusion that the person that was more willing to accept TCM treatment,their score of body pain would be higher(counting the score conversely,the extent of body pain is lighter). Therefore,their quality of life is better.On the aspect of behavior,the people that used more health behavior and health care methods of TCM have higher scores on physiological function,energy,social function,emotional health and body pain in quality of life.Conclusion:1.The items of the investigation questionnaire of TCM KAP was screened and determined by Delphi expert consultation method,and it met the requirements after reliability and validity evaluation,which could be taken as the tools to measure the TCM knowledge,faith and behavior investigation for community citizens,as well as the spread in the future work.2.The grasping extent of the eider citizens in the community with TCM characteristics-the community work adopted the holistic concept of TCM was better than that of the ordinary community,and they are more confident in TCM,and more willing to accept the measurements and methods of TCM treatment, health care,rehabilitation,health cultivation,dietary care and body building.In daily life,comparing with the elder citizens of ordinary community,those in TCM community use health care and dietary care methods of TCM more frequently,they accepted more therapeutic methods of TCM, furthermore,they often practice the body building arts of TCM,and use the psychological adjustment ways of TCM.It also reflects the work of TCM spreading in the community with TCM characteristics,the influence on the citizens in TCM knowledge,faith and attitude exceeds that of the ordinary community,which indicated the effort and effect of work.3.As to the elder citizens in the TCM community,the total score of SF-36 simple quality of life scale,as well as the score of physiological functional authority,overall health,energy,feeling function and body pain respectively, was higher than that of the ordinary community,and it indicated that the health condition of the elder citizens in TCM community was better than those in the ordinary community if quality of life was taken as the final evaluation index. It also reflects that the application of the holistic concept of TCM makes the elder citizen’ s quality of life better than those in the ordinary community to some extent,which proves the effect of the application of TCM holistic concept is affirmative,and its influence on quality of life is positive.4.The statistical analysis of the relation between the score of the investigation questionnaire of TCM KAP,and that of SF-36 simple quality of life scale indicated that TCM community has positive influences on the total score of quality of life,the score of physiological function,physiological functional authority,feeling function and body pain respectively,which means it can enhance the overall quality oflife,improve the physiological function, physiological functional authority,feeling function and body pain.5.The shortcoming and insufficiency of cross-sectional study is that its demonstration power of the inference of causal relationship is relatively poor, therefore,the results in the comparison of quality of life between TCM community and Not-TCM community would be more persuasive,if random control or prospective cohort study could be used in the further researches,indexes of TCM work with more standard and quantification were applied for the intervention design,and the intervention factors were controlled.Finally, the qualities of the citizens in TCM community and Not-TCM community were compared,and the results would be more persuasive.更多还原