【作者】 钟文娟；

【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， 2008， 博士

【摘要】 研究目的:随着社会经济的快速发展和人们生活水平的提高,严重精神疾病患病率和心理行为问题的发生率呈明显上升趋势,精神卫生问题已成为重大的公共卫生问题和突出的社会问题。精神疾病的增加,给社会和家庭造成巨大压力。为了尽可能减少和避免患者精神衰退,有利于心理康复,回归社会,同时减轻家庭和社会负担,社区精神卫生服务应运而生。社区精神卫生服务是一种新的医疗方式,也是社会发展的需要。本课题通过了解社区居民、社区医务人员及社区管理人员精神卫生服务需求,对社区居民心理健康、生活事件、社会支持、应对方式进行研究,建立心理预警模型,分析其相互关系及内在作用机制,为维护和促进社区居民的心理健康提供理论依据。本研究对社区居民心理健康问题的预防和早期干预具有重要的指导意义,并可为我国社区精神卫生服务的管理、相关卫生政策的制定提供科学依据。研究方法:1、文献法通过查阅相关文献资料,为本研究提供基本理论依据。2、专家咨询对社区卫生服务人员、有关专家、研究人员等进行咨询,用于设计调查问卷、选择所需心理调查量表。3、现场调查方法在武汉市选取4个社区,以入户方式随机抽取18岁以上的成人1167名进行调查。并随机抽取社区医务人员101名、社区管理人员82名进行调查。4、统计分析方法采用卡方检验、方差分析、多元线性回归分析、Logistic回归分析、AMOS4结构方程模型等统计方法进行分析。5、半结构访谈根据事先确定的问题对社区医疗管理人员进行访谈。研究内容:应用设计的社区精神卫生服务需求问卷对社区医务人员、社区管理人员、社区居民进行调查,研究社区精神卫生服务需求的情况,并分析精神卫生服务对社区居民生活工作有影响的因素;对社区卫生管理人员进行访谈;对社区居民作生活事件量表、应对方式、社会支持、症状自评量表(SCL-90)的测试与调查,分析其相互关系,从个体和生活事件角度研究社区居民心理健康的预测因素,从应对方式和生活事件角度研究社区居民心理健康的危险因素和保护因素,对社会支持与生活事件、心理健康之间的关系和作用机制进行研究,构建社区居民心理预警模型;结合精神分析理论、社会学理论、认知理论、心理应激、健康教育等相关理论进行分析。根据上述研究分析,提出我国建立社区精神卫生服务的重要性以及社区居民心理预警机制和防治措施,并构建了适合我国社区精神卫生服务的心理卫生服务模式。研究结果:1、大部分社区医务人员、社区管理人员、社区居民认为社区需要有精神卫生服务,不同文化程度、不同性别、不同收入、不同年龄、不同婚姻状况的社区居民对社区精神卫生服务的需求是不相同的。2、根据SCL-90的筛查结果,发现有心理问题者353人,心理问题总检出率达30.2%。男、女社区居民心理问题检出率分别为26.42%和32.32%,两者比较有显著性差异,女性明显高于男性。社区居民SCL-90评分除了躯体化与焦虑两因子与常模比差异无统计学意义外,其他因子得分差异有统计学意义;不同性别、不同文化、不同年龄、不同婚姻的社区居民在SCL-90评分、应付方式、社会支持方面,某些因子比较差异有统计学意义。3、社区居民在心理健康、社会支持、应对方式方面进行差异性分析发现,某些因子与婚姻、文化、性别、年龄存在显著交互作用。4、社区居民生活事件调查发现,在家庭有关问题坏事方面发生最多的事件是家庭经济困难,在工作学习有关问题坏事方面发生最多的事件是工作学习中的压力大,在社交与其他问题坏事方面发生最多的事件是被人误会、错怪、诬告。在家庭有关问题好事方面最多的事件是恋爱或订婚,在工作学习有关问题好事方面最多的事件是开始就业、其次是突出的个人成就。生活事件刺激量评分比较,性别在学习工作方面比较差异有统计学意义,其他方面比较差异无统计学意义;不同婚姻、不同文化、不同年龄的社区居民在某些生活事件方面比较差异有统计学意义。5、相关分析表明,社区居民家庭有关坏事、工作学习坏事、社交等问题坏事与SCL-90各因子呈正相关,家庭有关好事、工作学习好事与SCL-90某些因子呈正相关。社区居民应对方式中解决问题与客观支持、主观支持、支持利用度、支持总分呈正相关,求助与客观支持、支持利用度、支持总分呈正相关;自责、幻想、合理化与客观支持、主观支持、支持利用度、支持总分呈负相关,退避与客观支持、主观支持、支持总分呈负相关。6、以SCL-90总分为因变量,生活事件各因子及婚姻、文化、年龄、性别为自变量做多因素逐步回归分析,结果显示文化程度、婚姻状况、家庭问题坏事、工作学习问题坏事、社交及其他问题坏事对心理健康有显著的预测作用(p<0.05)。7、将心理健康作为因变量(两分类变量:SCL-90因子中有1项或1项以上2分者为1,SCL-90因子分均<2分者为0),应对方式各因子为自变量,进行二项分类Logistic逐步回归多因素分析,结果显示解决问题、自责、幻想被选入模型,其中自责和幻想的OR值最高,为危险因素;解决问题为保护因素。将心理健康作为因变量(两分类变量:SCL-90因子中有1项或1项以上2分者为1,SCL-90因子分均<2分者为0),生活事件各因子为自变量,进行二项分类Logistic逐步回归多因素分析,结果显示家庭有关坏事、工作学习坏事、社交等问题坏事被选入模型,被选入的三个因素均为危险因素。通过预警模型可及时发现有心理问题的社区居民,对他们进行早期预防干预,防止心理疾病的发生。8、对社区居民生活事件、社会支持与心理健康的结构方程模型进行拟和检验,发现整合模型的各种拟和度指标均高于独立模型,整合模型具有较高的拟和度和稳定性。表明社会支持在生活事件对心理健康的影响方面起着中介调节作用,社会支持不足将有损心理健康。结论与建议:生活事件中家庭问题坏事、工作学习问题坏事、社交及其他问题坏事、文化程度、婚姻状况等对社区居民心理健康有预测作用,自责、幻想是心理健康的危险因素,解决问题为心理健康的保护因素;社会支持对生活事件的应激具有较大的调节作用。因此,社区精神卫生服务机构应指导社区居民利用社会支持,在应对方式上多应用解决问题成熟型方式,少自责、幻想;要重视高文化程度及其他婚姻状况人群的心理情况,对生活中出现家庭有关问题坏事、工作学习问题坏事、社交及其他问题坏事的社区居民及时提供心理卫生服务,预防和减少精神疾病的发生。政府应加强对精神卫生服务的投入,提高社区精神卫生服务专业人员素质,并扩大宣传力度;建立以预防为主,以需求为向导的治疗机制,满足不同人群的精神卫生服务需求;合理配置卫生资源和服务内容,降低医疗费用的支出。建议社区精神卫生服务机构采用建立心理档案、实施心理测评、早期发现心理问题、及时预防、有效干预等“五位一体”的心理卫生服务模式,给每一位参加心理测试的社区居民建立心理档案,并根据所测指标统计得分,划分为轻度预警、中度预警、重度预警等几种类型。做到心理问题及早发现、及早预防、及早干预。充分利用社区的人、财、物、信息资源,达到精神疾病预防及提高社区居民心理健康的目的。创新:本研究在对我国社区精神卫生服务需求、社区居民心理状况、生活事件、社会支持、应对方式、不同群体社区居民特点及关系进行研究的基础上,运用结构方程模型、多元回归及Logistic回归分析,探讨了社区居民心理健康的预测因素、危险因素、保护因素;对社会支持与心理健康、生活事件的作用机制进行了研究;建立了社区居民心理预警模型,通过预警模型可以检测出社区居民的心理健康情况,发现需要心理预防干预的社区居民。提出了在社区精神卫生服务中应构建:心理档案、心理测评、早期发现心理问题、及时预防、有效干预“五位一体”的心理卫生服务模式。更多还原

【Abstract】 Research purposes:With the rapid development of social economy and the improvement of people’s standard of living, the prevalence of severe mental illness and the incidence of psychological problems have a clear upward trend. The mental health problems have become a major public health problem and outstanding social issues. The increase of mental illness cause tremendous pressure to social and family. In order to minimize and avoid recession of the patients spirit, be propitious to patients’psychological rehabilitation so as to return to society, and reduce the burden of the family and society at the same time, the community mental health services has emerged.The Community mental health service is not only a new medical treatment, but also the needs of social development. By knowing the needs of community mental health services of the community residents, the community medical staff and the community management, this project studies on the community residents’psychological health, life events, social support and coping style, creat a psychological early-warning model to analyze their mutual relations and internal mechanisms, and provide a theoretical basis to safeguard and promote the psychological health of community residents.The project is of great important guiding significance for the prevention and early intervention of the psychological health problems among the community residents, and it provides a scientific basis for the management of our community mental health services and the establishment of health policy.Methods:1. Literature search The study regarded theories of spirit analyse, cognitive, psychological stress and sociology as the theoretical foundation, through consulting professional magazines, journals, memoir and on-line information retrieval related literature, and collecting relevant research data of community mental health services, community health services, life events, mental health, social support, coping styles and other both at home and abroad, to provides the basic theoretical framework of the research.2. Experts consultationThe staff of community Health Service, relational experts, researchers and so on were consuted for the design of survey questionnaires and selecting the scale of the necessary psychological research.3. Scene investigation methodAccording to the research purposes, four communities were selected in Wuhan City, 1,167 adults who were over the age of 18 were selected randomly and were investigated in households methods. 101 medical staff and 82 community management staff were selected randomly for the investigation as well.4. Statistical analysis methodAccording to the property of the information, the statistical analysis methods were used , such as the chi-square test, multiple linear regression, Logistic regression analysis, AMOS4 structural equation model.5. Semi-structured interviewThis was based on understanding the needs of the mental health to the community residents, community managers and medical staff , in accordance to prior questions to interview community medical management so as to collect and in-depth information and data.Contents:Use the designed questionnaire about needs of community mental health service to investigate the community medical staff, the community managers and community residents, to interview community health managers, to test and survey the community residents with Life Event Scale, Coping style, social support and SCL-90; and analysis the relationship and the fuction mechanism of them, to study the prognostic factors, dangerous factors and protective factors on the psychological health; to estable psychological early-warning model of community residents, and combine the related theory to analysis it, such as sociology theory, cognitive theory, psychological stress, health education and so on; to construct the psychological health service model of community mental health services which fits our country.Results:1. The majority community medical staff, community managers and community residents thought that the community should have mental health service. There were different needs of the community mental health service in education, gender, incomes, ages, marital.2. Detective rate of psychological problem: 353 persons were detected with psychological problem according to SCL-90 results. The totle detective rate accounts for 30.2 %. Detection rates of psychological problems of male and female community residents were 10.44% and 19.56%, and there was a significant difference between men and women. Female’s rate is significantly higher than the male’s. By investigating the SCL-90 scor of community residents, the score difference of factors has statistical significance apart from factors of somatization and anxiety with nation-wide norm in China. The result showed that there were significant difference among different sex, cultures, ages and marital of community residents in the certain factors of SCL-90, social support and coping styles.3. There were significant interactions of certain factors with marriage, culture, gender, age in the psychological health of community residents, social support and coping style.4. The investigate of life events among community residents found that the most frequent incidents of the worse aspects of family-related problems are economic difficulties, the most frequent incidents of the worse aspects of work and study related problems are work and study pressure, and most frequent incidents of the worst aspects of sociality and other problems are misunderstandings, Cuguai, false accusations. The most frequent incidents of the best aspects of family-related problems are love or engagement. The most frequent incidents of the best aspects of work and study problems are the beginning of employment, followed by the outstanding individual achievement. With the comparison of the scores of life events’stress, there is significant difference sex in the aspects of work and study while others are not. There were significant differences among different marriage, different cultures, different ages community residents in some factors of life events.5. The bad aspects of community residents’families, work and study, sociality and other problems were positively correlative with the some factors of SCL- 90, while the good aspects of community residents’families, work and study were positively correlative with the some factors of SCL- 90. In community residents’coping styles, the solving problem was positively correlative with the objective support, subjective support and the extent of support use and totle scores of support. The assistance was positively correlative with the objective support, the extent of support use and the total scores of support. While self-accusation, fantasy and rationalization were negatively correlative with the objective support, subjective support, the extent of support use and the total scores of support; and retreat were negatively correlative with the objective support, subjective support and the total scores of support.6. The result of a multi-factor stepwise regression analysis, with the total score SCL-90 as dependent variable and factors of life events, marriage, culture, age, sex as variables, showed that education degrees, marital status, incidents of family-related bad incidents, bad incidents of work and study, bad incidents of sociality problems have significant prognostic effect on the psychological health (p <0.05).7. The results of a logistic multi-factor regression analysis by binomial classification, with psychological health as dependent variable (dichotomized variable : SCL-90 factors which has 1 item or above with scores equal or bigger than 2 are valued 1, while thoses with an average score smaller than 2 are valued 0) and all factors of coping style as independen variables, showed that solving the problem, self-accusation and fantasy were modeled, in which the OR scores of fantasy and self-accusation were high and were dangerous factors, while the solving the problem was found to be the protective factors .The results of a logistic multi-factor regression analysis by binomial classification, with psychological health as dependent variable (dichotomized variable : SCL-90 factors which has 1 item or above with scores equal or bigger than 2 are valued 1, thoses with an average score smaller than 2 are valued 0) and all factors of life events as independen variables, showed that the family-related bad incidents, bad incidents of work and study and bad incidents of sociality problems were modeled, in which three factors were dangerous factors.We can timely found the community residents of psychological problems through early warning model, and those of community residents can be early prevented and intervented and prevent them having mental diseases.8. The degree of fitting test to the structure equation model of life events, social support and psychological health of psychological health of community residents found that various of fitting indices of the integrated model were higher than those of the independent model, and the integrated model has higher degrees of fitting and stability. The social support has regulatory effects on the stress of life events to the residents’psychological health.Conclusion and Suggestion:With regard to the bad incidents of family problems, work or learning problems, sociality and other problems in life events, educational degrees and marital status have significantly prognostic effect on the psychological health of community residents. The fantasy and self-accusation are the risk factors of psychological health, and solving the problem is the protective factors of psychological health.The social support has greater regulatory effects on the stress of life events, we should guide community residents to take advantage of social support and make more use of solving the problem, which is a mature way, less self-reproach and illusions as well. The psychological situation of people with higher education and other marital status should be attended importance to. And the community residents which have the bad incidents of family problems, work and learning problems, sociality and other problems should be provided with mental health knowledge, to prevent and reduce their mental diseases.The community should carry out mental health services actively. While the government should step up investment in mental health services, expand its propaganda efforts, focus on prevention, set up an effective treatment mechanism, improve professional qualities of community mental health services, use demands as guide to meet the needs of different groups of people, reasonably allocating health resources and services, and reduce medical expenses. Community mental health services should be established the psychological health service model of "five in one", which are psychological files, psychological examination, early detecting psychological problems, the timely prevention and effective intervention. Every community residents who has participate the psychological test should be created a psychological file, and be measured off early warning mild, moderate warning, severe warning in accordance to Statistical score of the tested indexes. And psychological problems should be early detection, early prevention and early intervention.Our government should attach importance to the community mental health services, increas the investments of community mental health services,improving the professional qualities of community medical staff, the use of community people、money、goods、information resources to reach the goals of prevention of mental illness and promotion of psychological health of community residents.Innovation:Base on the research of the needs of community mental health service, psychological status of the community residents, life events, social support, coping styles and different groups of people’s characteristics and relationship in our country, from the view of the establishment of psychological early-warning model of community residents which uses structural equation model, multivariate regression and Logistic regression analysis, we discuss the psychological health forecast factors, dangerous factors and protective factors, and fuction mechanism of social support, mental health and life events. Through the early warning model we can find community residents who need psychological prevention and intervention.In addition, the research attempts to regard life events as a source of stress, starts from the evaluation of the mental stress response, psychological defense mechanisms and cognitive, by researching life stress of community residents and needs of community mental health service, and combines cognitive behavioral and learning theory ,social science, health education and other disciplines’theories, and puts forward that the community mental health services is low net of the tertiary network of mental illness. The tertiary prevention is of important guiding significance to community mental health service, and health education, health promotion and health advocacy play an important role in the aspect of prevention and cure of the psychological health of community residents. Community mental health services should be established: Psychological files, psychological examination, early detection of psychological problems, the timely prevention and effective intervention, that is "five in one," the psychological health service model.更多还原