【作者】 陈晶；

【导师】 罗仁；

【作者基本信息】 南方医科大学 ， 中西医结合临床， 2009， 博士

【摘要】 目的亚健康是目前国内医学研究的热点领域之一,诊断是亚健康研究中至关重要的问题,是开展其他亚健康研究的前提和基础,而量表评价是亚健康的主要诊断方法。我们提出“生存质量评价”为主、“亚健康常见症状”为辅作为亚健康诊断策略。祖国医学从《内经》即建立了治未病的重要理念,对亚健康研究具有深刻影响。中医体质是先天因素与多种后天因素共同作用的结果,对亚健康的发生、发展和演变具有重要影响。本研究旨在:(1)使用高度概括性问题的生存质量评定方法为主,与具有亚健康特征性、代表性、普遍性的常见症状问题相结合,从不同维度构建“亚健康自评量表”(Sub-health Self-rating Scale,SSS),并检验其信度和效度;初步建立大学生人群亚健康评判模型;(2)了解大学生亚健康中医体质的分布,探析该人群亚健康与中医体质间的关联。方法(1)亚健康自评量表的编制(包括三个阶段)第一阶段为量表构建阶段。对大学生进行整群抽样,使用亚健康量表草本进行调查,获得样本5599例,采用世界卫生组织生存质量简表(WHOQOL-BREF)作为效度参考;分析量表草本的结构效度、效标关联效度、区分效度和内部一致性信度。选用采用离散程度法、相关系数法、因子分析法、区分度分析法及克朗巴赫α系数法等方法对条目进行分析与筛选,获得亚健康自评量表。第二阶段为量表考评阶段。对大学生进行整群抽样并获得有效样本6205例,对量表进行可行性分析、信度分析及效度分析。信度分析采用内部一致性信度及分半信度。效度分析采用一阶、二阶探索性因子分析、验证性因子分析考评量表与理论结构的合理性、正确性,以及采用相关分析考核分量表的一致性。第三阶段为大学生人群亚健康评判模型的初步建立。采用百分位法,以现患率为划分界,建立大学生亚健康临床参考评判分值表,随机抽出1000例问卷进行专家定性评判,将专家定性评判法及分值评判法两种方法的评判结果进行Kappa吻合度考核。最后,采用Logistic回归方法建立“3+1”评判的模型。(2)大学生亚健康中医体质研究(包括四个方面)将大学生体质分为平和、血瘀、气虚、气郁、阴虚、痰湿、湿热、阳虚和特禀体质9种,使用中医体质量表和亚健康自评量表对6205名大学生进行流行病调查。第一方面为大学生亚健康的分布及分析:描述大学生亚健康的分布状况,使用χ~2检验对不同性别、独生子女、年级、专业、民族的大学生亚健康分布状况进行比较分析。第二方面为大学生中医体质的分布及分析:描述大学生中医体质的分布状况,使用χ~2检验对不同性别、民族、籍贯大学生的中医体质进行比较分析。第三方面为亚健康大学生中医体质的分布及分析:描述亚健康大学生中医体质的分布状况,描述偏颇体质在亚健康大学生中的分布情况并进行频数分析,描述复合体质在亚健康大学生中的分布情况并进行频数分析,使用χ~2检验对不同性别、民族、籍贯的亚健康大学生的偏颇体质进行比较分析。第四方面为中医体质与大学生亚健康的相关性分析:采用非条件Logistic回归方法,分别建立4个模型,即中医体质与亚健康的回归模型,中医体质与3个不同亚健康亚型的回归模型,对模型进行假设检验及拟合优度检验。结果(1)亚健康自评量表的编制第一阶段(量表构建阶段):①效度分析:结构效度采用探索性因子分析(Varimax正旋转法),按特征根值＞1提取其因子,共提取16个因子,累及贡献率为52.29%;效标效度结果显示总表及各领域与WHOQOL-BREF存在显著正相关关系(r＞0.60,P＜0.000);区分效度结果显示大学生亚健康人群的调查表总分及各领域原始分值均低于大学生健康人群(t＞35.00,P＜0.000)。②信度分析:内部一致性信度检验结果显示总的Cronbach’sα系数为0.949,其躯体、心理、社会3大领域的Cronbach’sα系数分别是0.906,0.881,0.865,有8个因子的Cronbach’sα系数达到0.7以上。③条目筛选:通过5种项目分析方法,从亚健康量表草本中筛出63项条目作为量表条目池,从专业角度出发,根据条目的普遍性、代表性删除9个题项,保留条目54条,并新增4条皮肤因子条目,共由58个条目组成量表。第二阶段(量表考评阶段):①量表可行性分析:接受率为89.03%,应答率为99.67%,完成量表时间在10分钟之内。②信度分析:内部一致性信度测得总量表Cronbach’sα系数为0.942,躯体、心理、社会领域的Cronbach’sα系数分别是0.915,0.856,0.850,各因子的Cronbach’sα系数在0.88-0.72之间;分半信度测得总表条目的分半信度为0.938;躯体、心理、社会领域分别是0.933,0.890,0.881,各因子的分半信度在0.73-0.90之间。③效度分析:一阶探索性因子分析(Varimax旋转法),量表中有12个共因子(方差累积贡献率为60.53%),结合碎石图及相关理论,考虑抽取10个因子(方差累积贡献率为56.63%)。因子命名为:F1:负性情绪因子,F2:正性情绪因子,F3:躯体不适因子,F4:能力因子,F5:睡眠因子,F6:消化机能因子,F7:社会关系因子,F8:疲劳因子,F9:皮肤因子,F10:小便因子。二阶探索性因子分析(Promax斜交旋转法),获得2个公因子(方差累积贡献率为56.55%),FⅠ包含了6个躯体因子,FⅡ则包含了心理和社会4个因子,提示心理和社会因子间的相关程度较大。结合理论构想,将量表分为躯体、心理和社会3个维度。验证性因子分析证明3维10因子二阶因素理论结构模型与测验变量拟合良好,支持该量表的理论结构(GFI=0.86,CFI=0.96,AGFI=0.85,RMSEA=0.055,NFI=0.961,IFI=0.963,TLI=0.961)。内容效度:各条目与其所属因子间存在较强的相关性(相关系数r在0.51-0.88之间);各因子与其所属领域之间相关性较强(相关系数r在0.52-0.89之间),而与其他领域的相关性较弱;各领域得分与量表总分之间相关性均较强(相关系数r在0.77-0.93之间)。P值均在0.001的水平,具有统计显著性意义。可以认为该量表具有较好的内容效度。第三阶段(评判模型建立阶段):①初步制定关于大学生人群在亚健康自评量表中的临床参考百分位划分线:即总表百分位划分线为60%;躯体亚健康子量表百分位划分线为50%;心理亚健康百分位划分线为35%;社会亚健康百分位划分线为35%。评判亚健康总表的原始粗分、转化分和T分数分别为224、72、52;躯体型亚健康子量表的原始粗分、转化分和T分数分别128、72、50;心理型亚健康子量表的原始粗分、转化分和T分数分别为48、60、46;社会型亚健康子量表的原始粗分、转化分和T分数分别为26、56、45。各项分值越低表示越不健康。②专家定性评判与各领域分值、总分评判的K值均达0.7以上,吻合度较强。③“3+1”评判模型预测结果显示模型拟合指数χ~2=0.188,P=0.664;总判对率为93.0%;Nagelkerke R~2为0.772,提示该模型具有较好的预测率与解释能力。(2)大学生亚健康中医体质研究大学生亚健康的分布及分析:疾病人群占2.84%,健康人群占34.65%,亚健康人群占62.51%。亚健康现患率女生高于男生(χ~2=78.915,P=0.000),非独生子女高于独生子女(χ~2=6.879,P=0.009),低年级学生高于高年级学生(χ~2=17.440,P=0.002),人文社科及外语专业学生高于其他专业(χ~2=20.987,P=0.000)。大学生中医体质的分布及分析:平和体质占67.8%,偏颇体质占32.2%。男生平和体质较多而女生的偏颇体质较多,提示女生的中医体质更具有倾向性;少数民族学生的气虚体质和痰湿体质较多,西北籍学生的阴虚体质较多,华南籍学生的血瘀体质较多。亚健康大学生中医体质的分布及分析:①健康大学生平和体质占95.8%,亚健康者偏颇体质占52.3%,提示亚健康大学生更易出现偏颇体质倾向;偏颇体质分布比例排序为:血瘀体质(48.10%)＞气虚体质(41.50%)＞气郁体质(35.60%)＞阴虚体质(31.90%)＞痰湿体质(29.20%)＞湿热体质(28.80%)＞阳虚体质(22.80%)＞特禀体质(15.60%)。②复合体质在亚健康偏颇体质人群中存在的比例较高(占61.10%)。③在亚健康大学生中,女生阴虚体质和血瘀体质的比例较高,男生气虚体质、气郁体质、痰湿体质、特禀体质的比例较高。④在亚健康大学生中,少数民族学生气虚体质和痰湿体质的比例较高。⑤在不同籍贯亚健康大学生的体质比较中,阴虚体质和血瘀体质的分布具有显著性差异(P＜0.05),其中阴虚体质以西北籍学生占的比例最高(占32.4%),华北籍学生占的比例最小(占12.7%);血瘀体质以东北籍学生占的比例最高(占26.5%),西北籍学生占的比例最小(占15.00%)。中医体质与大学生亚健康的相关性分析:通过Logistic回归分析建立了中医体质与亚健康的回归模型、中医体质与躯体型亚健康的回归模型、中医体质与心理型亚健康的回归模型、中医体质与社会型亚健康的回归模型等4个模型。①模型的假设检验:4个Logistic回归方程的均具有统计学意义(P＜0.01),说明中医体质与亚健康以及各亚型均具有较密切的联系。②模型的拟合优度检验:Nagelkerke R~2分别0.671(中医体质与亚健康的回归模型)、0.744(中医体质与躯体型亚健康的回归模型)、0.452(中医体质与心理型亚健康的回归模型)、0.388(中医体质与社会型亚健康的回归模型);总判对率依次分别为86.00%、87.40%、78.80%和78.00%;Hosmer-Lemeshow模型拟合优度指数显示,中医体质与躯体型亚健康的回归模型较高(χ~2=3.971,P=0.860),说明模型与实际数据的吻合情况十分理想,而其余3个模型的拟合优度指数不理想,即χ~2(46.0-20.0),P＜0.000,说明尚有其他的亚健康表现未被包括在模型中。结论(1)完成了亚健康自评量表的构建工作,可作为亚健康的测评工具。条目分析具备有较好的敏感性、代表性、独立性、重要性及内部一致性。可行性研究表明,该表的接受率、应答率及完成量表时间均达到了测量学的基本要求。信度研究表明,该量表Cronbach’sα系数、分半信度研究均达到了测量学的基本要求。效度检验表明,该量表的内容效度、效标效度、结构效度良好,但仍存在公因子累积贡献率不高,模型不够简约等不足。(2)初步建立了“3+1”评判的模型,为亚健康的评判、防治效果的评价提供科学依据。采用百分位法,以大学生亚健康现患率进行百分位临床划界分,建立了大学生人群亚健康原始粗分、转化分和T分数等评判分值表,初步建立了“3+1”评判的模型,结果提示该模型具有较好的预测率与解释能力,在一定程度上证明了模型设想的科学性和合理性,可以作为亚健康自评量表的框架。(3)初步证明了中医体质对亚健康的重要影响,为大学生亚健康干预研究提供依据。亚健康大学生具有明显的偏颇体质倾向,提示从健康到疾病的发展过程中,可能伴随着体质偏颇的演变,以至于最终形成疾病中的各种中医证型;瘀血体质和气虚体质在大学生亚健康人群较多见,特禀体质最少见;复合体质在亚健康大学生中存在的比例较高,说明亚健康大学生的体质特点倾向于复杂;不同性别、民族、籍贯大学生的中医体质分布存在一定的差异,符合中医学“三因制宜”理论;Logistic回归分析的结果证明,中医体质与亚健康密切相关,其中与躯体性亚健康的联系十分密切。更多还原

【Abstract】 ObjectiveAt home,sub-health is currently a hot topic in the research area.Meanwhile,the diagnosis of sub-health is the important question,which is basis and prerequisite for developing sub-health.The development of scale is the diagnosis method.Based on the dominant role of "evaluation of quality of life" and the subsidiary role of "common symptom of sub-health",we put forward the theory of assumptions,and introduce the ideas of developing sub-health scale.According to the theory of "Preventive Treatment of Disease" of Nei Jing,it has deep effect on the research of sub-health.It is the people’s result of congenital and acquired factors that TCM construction is formed,which has great influence on development and evolution of sub-health.The purpose of this study:To develop Sub-health Self-rating Scale(SSS);to examine the reliability and validity of the scale;to initially establish the evaluation model of sub-health among undergraduate students;to study TCM construction of Sub-heahthy undergraduate students;to explore the correlation between sub-health and TCM construction.Methods (1) The development of Sub-health Self-rating Scale(SSS) was divided into three stages.The first stage was Construction of the scale samples.Through cluster sampling, 5599 undergraduate students were selected and studied.The reliability and validity of the Second-generation Sub-health Questionnaire(Draft of SSS) were examined.The reliability verification applied generalizability coefficient;the validity verification included the factor analysis to verify the validity,criteria validity and discriminant validity.Five methods based on dispersion,correlation coefficient,factor analysis, t-test and Cronbach’sαwere employed to analyze the items,and the preliminary samples composed of the 10 factors,3 subscales were generated.The second stage was scientific evaluation of SSS.Thought cluster sampling, the paper was filled in by investigator.6205 undergraduate students were selected and studied.The scale was conducted feasibility analysis.Exploratory and confirmatory factor analysis of 1-order Factor and 2-order Factor were used to evaluate the infra-structure of the scale.The reliability analysis included Cronbach’sα,split-half reliability and the mean inter-item correlation.The validity analysis included content and construct validity.The third stage was initial establishment of the sub-health evaluation model among undergraduate students.The clinical sub-health reference value tablelet, including original score,transformed score and T score,was made out by percentile method,according to the dividing line of the prevalence rate of sub-health among undergraduate students.Meanwhile,1000 valid questionnaires by random sampling were used to evaluate the goodness of fit between expert evaluation method and score value method.According to our assumption,we initially established the triadic evaluation model of sub-health among undergraduate students.(2) Study on TCM construction among sub-healthy undergraduate students included four aspects.Thought field survey,6205 undergraduate students were surveyed by Sub-health Self-rating Scale(SSS) and the Constitution in Chinese Medicine Questionnaire (CCMQ),and were divided into 9 TCM constitutions.The data were analyzed with Frequencies and Chi-square test.The first aspect was to distribute and analyze sub-health of undergraduate students.The second aspect was to distribute and analyze TCM constitution of undergraduate students.The third aspect was to distribute and analyze TCM constitution of sub-healthy undergraduate students.The fourth aspect was to explore the correlation between and TCM construction sub-health among undergraduate students.4 logistic regression models were set up and analyzed.Results(1) The development of Sub-health Self-rating Scale(SSS)In the first stage was the scale construction.①Validity analysis:The method of construct validity was factor analysis.There were 16 factors that the Eigenvalue was above 1.The Cumulative Proportion was 52.29%.The result of the criterion validity was showed that the correlation of the questionnaire total score with the score of WHOQOL-BREF was high(r>0.60),which were statistically significant (P<0.001).The result of distinguish validity was showed that there were notability difference in mean scores between the undergraduate students of health and Sub-health in the dimensions(t>35.00,P<0.000).②Reliability Analysis:The Cronbach’s alpha of the total questionnaire was 0.949,the dimensions of body,mood, and society had high reliability,0.906,0.881,0.865 respectively,but only 8 factors were up to 0.7.③Item analysis:It indicated that 63 items kept in the Second-generation Sub-health Questionnaire had satisfactory sensibility, representation,independence,significance and internal consistency.From a professional perspective,we deleted 9 items,maintained 54 items,and added 4 item of skin factor.The scale was consisted of 58 items.The second stage was evaluation scale.①Feasibility analysis:Acceptance rate and finish rate were 89.03%and 99.67%respectively.Answer time of SSS was in 10 minutes.②Reliability Analysis:Internal consistency analysis showed that the Cronbach’s alpha of the total scale was 0.942,the dimensions of body,mood,society had high reliability,0.915,0.856,0.850 respectively,each factor was up to 0.7. Split-half reliability of the total scale was 0.938,that of the dimensions of body, mood,society was 0.933,0.890,0.881 respectively,that of each factor was from0.73 to 0.90.③Validity analysis:The method of construct validity was exploratory factor analysis 1-order Factor(Varimax).There were 12 factors that the Eigenvalue was above 1.The cumulative proportion was 60.53%.Based on screen plot and related theories,there were 10 factors that be extracted.The cumulative proportion was 56.63%.10 factors were labeled as follows:F1:negative emotion,F2:positive emotion,F3:body discomfort,F4:capability,F5:sleep,F6:digestive function,F7: social relationship,F8:fatigue,F9:skin,F10:urine.The result of 2-order Factor exploratory factor analysis(Promax) was showed that there were 2 factors that the Eigenvalue was above 1,the cumulative proportion was 56.55%.FⅠwas included 6 factors of physiological dimension;FⅡwas included 4 factors of psychological and social relationship dimensions.From a professional perspective,Sub-health Self-rating Scale was composed of 3 dimensions.The indexes of confirmatory factor analysis(2-order Factor of 3- dimensions and 10- factors) met the requirement of Sub-health Self-rating Scale(SSS) measurement(GFI=0.86,CFI=0.96,AGFI=0.85, RMSEA=0.055,NFI=0.961,IFI=0.963,TLI=0.961).The correlation coefficient between each item and factor was 0.51-0.88.The correlation coefficient between each factor and it’s own domain was 0.52-0.89,and lowly correlated to other domains.The correlation coefficient between subscale and total scale was 0.77-0.93,which were statistically significant(P<0.01).The third stage was initially established the evaluation model of sub-health among colledge students.①The clinical sub-health reference value tablelet: Percentile divided line of the total score of SSS was 60%,Percentile divided line of physiological field was 50%,Percentile divided line of psychological field was 35%, Percentile divided line of social relationship field was 35%.The original score, transformed score and T score of the total scale were 224,72,52 respectively.The original score,transformed score and T score of each subscale were 128,72,50 (physiological sub-health subtype);48,60,46(psychological sub-health subtype);26, 56,45(social relationship sub-health subtype).The lower score indicated that the worst of the health condition.②The goodness of fit between expert evaluation method and score value method were up to 0.70.③The results of the triadic evaluation model prediction showed that regression model had good prediction rate and interpreting ability(χ~2=0.188,P=0.664,Nagelkerke R~2=0.772,total of prediction rate 93.0%).(2) Study on TCM Construction among Sub-healthy Undergraduate studentsFirstly,the result showed that the total prevalence rate of mental sub-health among undergraduate students was 62.51%.The prevalence rate of sub-health in female was higher than that in male,in non-only-child than that in only-child,there were of statistical significance(P<0.05).A decreasing trend among different grades, the prevalence rate of sub-health decreased with the increase of grades(χ~2=17.440, P=0.002).Compared among various professional undergraduate students,health status of humanities and social sciences and foreign language specialty students were poor(χ~2=20.987,P=0.000).Secondly,the result showed that biased constitution among undergraduate students was in the minority.The proportion of normal constitution in male were higher than that in female,there were of statistical significance(P<0.05).The proportion of yin deficiency constitution and dampness-heat constitution in minority were higher than that in Han nationality,there were of statistical significance (P<0.05).The proportion of yin deficiency constitution among undergraduate students born in Northwest China was relatively higher.The proportion of blood Stasis constitution among undergraduate students born in Northeast China was relatively higher. Thirdly,①the result showed that sub-healthy undergraduate students were easier to tend of biased constitution than healthy undergraduate students.In order of decreasing percentage,the range was blood stasis constitution(48.10%),qi deficiency constitution(41.50%),qi depression constitution(35.60%),yin deficiency constitution(31.90%),phlegm-dampness constitution(29.20%),dampness-heat constitution(28.80%),yang deficiency constitution(22.80%),the specific endowment constitution(15.60%).②1849 students were biased constitution.38.90% were single constitution,61.10%were multiple constitution.③The proportion of blood Stasis constitution and yin deficiency constitution in female were higher than that in male,there were of statistical significance(P<0.05).The proportion of qi depression constitution,qi deficiency constitution,phlegm-dampness constitution and the specific endowment constitution in male were higher than that in female,there were of statistical significance(P<0.05).④The proportion of yin deficiency constitution and dampness-heat constitution in minority were higher than that in Han nationality,there were of statistical significance(P<0.05).⑤The proportion of yin deficiency constitution among undergraduate students born in Northwest China was relatively higher.The proportion of blood Stasis constitution among undergraduate students born in Northeast China was relatively higher.Fourthly,①Hypothesis Testing of the models:4 logistic regression models had statistical significance(P<0.01).②Goodness of fit test:Nagelkerke R~2 of the regression model of TCM Constitution and Sub-health,the regression model of TCM Constitution and Physiological Sub-health Subtype,the regression model of TCM Constitution and Psychological Sub-health Subtype and the regression model of TCM Constitution and Social Relationship Sub-health Subtype was 0.671,0.744,0.452 and 0.388 respectively. Total of prediction rate was 86.00%,87.40%,78.80%and 78.00%respectively. Goodness-of-fit index of Hosmer-Lemeshow model showed the regression model of TCM Constitution and Psychological Sub-health Subtype was good(χ~2 =3.971,P=0.860), which of another 3 logistic regression models were not ideal,χ~2(46.0-20.0),P<0.000.Conclusion (1) To develop Sub-health Self-rating Scale(SSS).Item analysis indicated that the items of SSS had satisfactory sensibility,representation,independence, significance and internal consistency.Feasibility analysis showed acceptance rate, finish rate and answer time of SSS achieved the demand of psychometrics.The index of reliability included the Cronbach;s alpha and Split-half reliability,achieved the demand of psychometrics.The structure validity achieved excellent levels of content, construct,and criterion-related validity.SSS can reflect the status and characteristic of sub-health in China and verified with the theory model and can be used to evaluate sub-health among undergraduate students.However,there were some deficiency,the cumulative proportion was not high enough,and the models of SSS need to be revised and reduced.(2) To initially the evaluation model of sub-health among undergraduate students.The clinical sub-health reference value tablelet,including original score, transformed score and T score,was made out by percentile method,according to the dividing line of the prevalence rate of sub-health among undergraduate students.The result showed that the evaluation model had good prediction rate and interpreting ability.To some extent,the model was scientific and rational to be the framework of SSS.(3) To elementarily prove TCM constitution has major influence on sub-health.Sub-healthy undergraduate students were easier to have tendency of biased constitution than healthy undergraduate students,which means the evolution law of biased constitution may change with the development from health to disease, and may finally form each kind of TCM syndrome types of disease.The more frequent constitutions among sub-healthy undergraduate students were blood stasis constitution and qi deficiency constitution,while the specific endowment constitution was rare.A large proportion of TCM constitution among sub-healthy undergraduate students was multiple constitutions,which suggested that distribution of TCM constitution was extremely complicated and a single constitution classification was rare.Distribution of TCM constitution among sub-healthy undergraduate students was different in gender,in birthplace and in nation,which accorded with the theory of "abidance by triple pathogens".TCM construction had high correlation with sub-health,especially with physiological sub-health subtype.更多还原