【作者】 王书梅；

【导师】 姜庆五；

【作者基本信息】 复旦大学 ， 流行病与卫生统计学， 2009， 博士

【摘要】 伤害是一个严重的公共卫生问题。尽管对死亡率和发病率的原因分析有着悠久的历史,但只是在近期公共卫生部门才认识到伤害和暴力是可以预防的。以社区为基础的伤害预防项目起源于20世纪80年代,并成为伤害预防的重要组成部分。以社区为基础的伤害预防项目是以社区中多部门合作、共同发现问题和寻找解决问题的方法为特征。然而,文献检索显示,我国在这方面的研究与探索相当有限。目的探索伤害在社区水平的流行现况和特征以及适合社区水平的伤害监测方法;探索高发伤害事故、高发场所和高危人群伤害事件的流行特征和外部原因,运用适当的统计模型分析其可能的影响因素,并对社区伤害预防策略提出建议。对象与方法1、以上海市某街道的全体居民为研究对象,被调查人员需在本街道至少居住两年以上。采用入户调查方法。入户调查问卷根据世界卫生组织“社区伤害和暴力调查指南”以及“伤害外部原因国际分类”自行设计。一份是“某某社区伤害发生及居民相关认知情况调查表”,另一份是“某某社区伤害发生个案登记表”。每户家庭由出生日期与调查当日日期最接近者回答问卷,年龄须介于16—70之间。第一份问卷一户填写一份。第二份问卷由回答问卷者回顾家庭所有成员自2007年1月1日至2007年12月31日期间伤害发生情况,每一次伤害填写一份问卷。有效调查9760户家庭,共记录25209人。2、所有在2007年1月1日至2008年12月31日到该街道社区卫生服务中心就诊的病人。使用“某某社区医院伤害报告卡”,所有因为伤害而就诊的患者均须填写此表,填表人为当班护士。3、所有居住在该社区的居民及由于各种原因经过本社区管辖范围的人员。时间范围为2008年1月1日至2008年12月31日。由当地交警支队收集所有发生在本社区的交通事故案件,包括通过人员、对讲机、巡逻和110等接警,并填写“道路交通事故伤害信息采集表”。4、研究社区所属的所有5所幼儿园,调查对象为幼儿家长和幼儿园教师,调查人数分别为966人和121人。采用自行设计的调查问卷,分为家长问卷和教师问卷两种。家长问卷包括基本情况、伤害相关知信、行为与习惯、家居方面和幼儿伤害情况5个部分;教师问卷包括基本情况、伤害相关知信和伤害源认知3个部分。结果1、入户调查结果显示:社区常住人口中,伤害发生率为0.52%,女性伤害发生率略高于男性,但差别没有显著性;65岁及以上年龄段伤害发生率最高,为1.15%,其次是45-64岁年龄组,为0.77%,伤害发生率呈现随年龄增加而升高的趋势,且差别检验有统计学意义;按文化程度分层,没上过学的一组伤害发生率最高,为0.85%,其次为小学毕业组,为0.73%,伤害发生率呈现随文化程度升高而降低的趋势,且差别检验有显著意义。在各种伤害中,跌落伤的发生率最高,为0.25%;其次为交通伤,发生率为0.15%。道路和居家是伤害发生最高的场所,分别占37.12%和27.27%。2、社区卫生服务中心伤害监测报告卡统计分析结果显示:到社区卫生服务中心就诊的伤者中以外省市户籍为主,占59.16%;职业分布统计结果显示生产运输设备操作人员最多,占31.49%。伤害发生主要地点是工业和建筑区域,占50.62%,居家伤害列第二为,为21.80%;伤害发生时从事的活动以正在工作为最高,占62.01%;伤害发生原因前两位为物体、器具的机械性作用和跌倒/跌落,分别占77.58%和16.90%。3、“交通事故信息采集表”分析结果显示:社区交通事故原因认定,第一位的为转弯的机动车未让直行的车辆或行人先行,选择百分比为30.59%;第二位为驾车时有其他妨碍安全行车的行为,选择百分比为12.88%;第三位为非机动车逆向行驶,选择百分比为8.77%。交通事故发生时当事人的交通方式以驾驶客车最多,其次为驾驶电动自行车、摩托车和骑自行车。交通事故影响因素分析显示:男性、年龄小于20岁组、外来务工人员、非机动车使用者和步行、乘车人比较容易发生伤害,甚至死亡。4、对幼儿家长问卷分析结果显示:幼儿伤害年发生率7.20%,男孩与女孩间和不同年龄间伤害发生差别没有显著性。非有意伤害占绝大多数,占94.69%;家中发生的伤害为第一位,占44.25%,其次是居住区和学校,分别为15.04%和14.16%;运动时发生伤害的比例最高,达47.79%,其次是旅游、基本日常生活和休闲/游戏;伤害性质以擦伤和表皮损伤最多,占54.87%;伤害机制跌落/跌倒居第一位,占54.87%,其次是物体或人撞击,占17.70%;头面部伤害发生几率最高,达40.71%,肩和上肢、下肢以及手指和脚趾所占比例均为19.47%;伤害程度以轻伤和浅表损伤为主,占56.64%。5、Logistic回归分析结果显示,人均住房面积越大,幼儿伤害发生越少。而人均月收入、父母是否上海户籍和母亲文化程度与幼儿伤害发生呈正关联,即人均月收入越高,幼儿伤害发生越多;父母是外地户籍,幼儿伤害发生较多;母亲文化程度越高,幼儿伤害发生越多。居家环境评分和幼儿行为评分结果与伤害发生关系比较显示,伤害组幼儿居住环境得分低于非伤害组,差别有显著性意义。6、社区居民对各类伤害事故的重要性和可预防性的认知调查结果显示,认为又很重要、又能够预防比例最高的伤害事故是煤气中毒和触电,分别为66.14%和63.30%,火灾排在第三位,为57.77%。比例排在后三位的是动物咬伤、运动/娱乐时受伤和犯罪,分别为21.13%、25.09%和33.28%。多水平模型评估显示家庭因素和户主因素对居家安全有着显著的影响,例如家庭人口数、人均居住面积、受教育程度、职业状况等。结论1、社区伤害事件普遍存在,社区干预项目应首先针对社区伤害发生的高危人群和高危场所,人群包括老年人、制造、建筑、交通运输业人员和儿童青少年,高危场所包括城市道路、住宅小区内道路、家和工业建筑区域。急救教育应该作为公民普及教育的一部分,应有相应的配套政策规定切实保证每一位公民接受培训。2、在交通事故涉及的人、车、道路三个环节中,干预的重点应放在人员方面,特别是机动车驾驶员和助动车驾驶员的干预。利用流行病学原理,定位在交通伤害发生不同阶段的宿主、病原体、媒介和社会与物质环境的相关危险因素,以寻求能够改变这些危险因素的方法。3、居家伤害和幼儿运动中伤害应作为幼儿伤害预防的重点,特别是居家环境和运动保护方面。幼儿监护人对幼儿伤害预防的认知存在误区,应加强监护人干预,包括家庭聘用的保姆。4、在目前国家或市级伤害监测体系尚不完善的情况下,可以同时利用多种渠道获取有关伤害数据,包括入户调查、社区卫生服务中心伤害报告卡和相关职能部门提供的数据,以达到较全面了解社区伤害发生现况和特征的目的,但与此同时也必需考虑社区的人力和物力资源情况。5、社区伤害预防必须有生态学的理念,既要关注个体因素,也要关注个体所处的物质环境和社会环境因素,包括教育干预策略和环境干预策略。教育策略应以理论框架为依据,环境改善或更新应在评估的基础上开展。更多还原

【Abstract】 Injury is a serious public health issue. Though the main causes of mortality and morbidity are as old as the human species, it is only recently that the public health sector has begun to regard violence and injuries as preventable. The community-based approach to injury prevention programs was developed in the 1980s and has since become an essential component of injury prevention. Community-based programs are characterized by collaboration among different community sectors and the involvement of community members to define the safety problem and find solutions. However literature review showed that very few researches and studies have been done in this field in China.Objective:To explore injury status and its characteristics and the suitable injury surveillance methods as well in community level. To explore what type of injury has high incidence rate, what kind of place is most common in terms of injury events, what population is vulnerable to injury, what are the characteristics for those high incidence injuries, vulnerable places and populations, and what are the external causes for those situations. To explore risk factors which may influence the happening of injury with statistic models, and to propose intervention strategies and plans for community injury prevention.Methods:1. All the residents in a community in Shanghai were as targeted population who has been living in this community at least for two years. Household survey was conducted. Two questionnaires were designed according to WHO’s "Guidelines for conducting community surveys on injuries and violence" and "International classification of external causes of injuries". The first questionnaire was "Survey on resident’s KAP on injury and related factors" and the second one was "Survey on injury event and related information". The person who’s birthday was most close to the date of investigation was chosen to answer to the questionnaire and who’s age must be over 16 years old and less than 70 years old. For the first questionnaire each family filled one form, however for the second one each injury case one form should be filled which recorded injury cases from 1st January to 31 December 2007. In total 9760 households were investigated and 25209 individual’s information was recorded.2. All the patients who visited the community health center from 1st January of 2007 to 31 December of 2008 were target population. Anyone who was diagnosed as a kind of injury would be interviewed by a nurse with filling an injury report form.3. All the residents living in this community or anyone passing through this community for any reason were target population. The time period was from 1st January to 31 December, 2008. The local traffic policemen were responsible for collecting all the information related to traffic accident event occurred in this community which included cased reported to them through people, interphone, patrol and 110 emergency call. A form of "Information collection on traffic accidents" was asked to answer.4. All five kindergartens located in this community were investigated with targeting on parents and teachers. In total 966 parents and 121 teaches were interviewed. The questionnaires were self-designed. There were two types of questionnaire. One was for parents and one was for teachers. The parent’s questionnaire had five parts including basic information, injury related awareness and perspectives, habits and behaviors, home safety and injury situation. The teacher’s questionnaire had three parts including basic information, injury related awareness and perspectives and indentifying on risk factors.Results:1. The household survey showed that among the local residents the injury incidence rate was 0.52%. The female had higher incidence rate than male but no significant difference was observed. The elderly with age of 65 or above had the highest injury incidence rate (1.15%), the following was people aged between 45 years old to 64 years old (0.77%). As the age getting older the injury incidence rate getting higher with P value less than 0.05. The higher the education level the less the injury (P<0.05). Among all types of injures the fall had the highest incidence rate (0.25%), then the traffic injury (0.15%). The road/street and home were the most common places where injury happened accounted for 37.12 % and 27.27 % for each.2. The injury report from community health center showed that the injury patients who visited the center were floating population dominated who accounted for 59.16% of all injury visitors. The occupational distribution suggested that people who worked with transportation, production and manufacture were the most vulnerable. The places that injury happened most were industry and construction field (50.62%) and home (21.80%). Working listed as first activity when injury happened (62.01 %). The top two reasons for injury were struck or hit by an object (77.58%) and fall (16.90%).3. Analysis of "information collection on traffic accidents" showed the identified top three causes for traffic incidents were the drivers of motor vehicles who were turning the corner didn’t let the other vehicles or pedestrians go first straight forward (30.59%); the drivers of motor vehicles disturbed other driver’s driving (12.88%); the drivers of non motor vehicles drove in converse direction (8.77%). At the time of traffic accident the mode of transportation of involved people were mostly car drivers, followed by drivers of scooter, motorcycle and cyclist. The population vulnerable to injury or even death were: male and aged less than 20 years old, floating population, drivers of non-motor vehicles, pedestrians and passengers.4. The survey to children’s parents showed: the injury incidence of children was 7.20% without significant difference between boys and girls and between different age groups. Unintentional injury was accounted for the majority of injury (94.69%). In terms of the places of injury 15.04% cases happened at home and 14.16% at school. The highest proportion of injury happened during sports related activities (47.79%), followed by travelling, daily life and leisure time. The nature of injury was mostly of bruise or superficial injury (54.87%). Fall was the first in term of injury mechanism (54.87%) followed by stuck or hit by person or object (17.70%). Head or face had highest frequency of getting injury (40.71%), followed by shoulder and upper limbs, lower limbs and toes or fingers which accounted for 19.47% for each. In terms of severity minor or superficial injury was the most (56.64%).5. Logistic regression analysis showed that the bigger the square meters per person occupying at home the less the children’s injury. The positive relationship was found between children’s injury and their family’s income per person, whether their parents as registered local residents, and their mother’s education degree. That means the higher the family income per person the more the children’s injury; children with their parents from outside Shanghai had higher injury incidence; the higher the children’s mother’s education level the higher the children’s injury incidence. Compare the score of home establishments and children’s behavior it was suggested that the group of children with injury had lower score significantly than that of group without injury.6. The survey of resident’s perspectives on importance and preventability of injury showed that the top three type of injuries that they thought which were important and preventable were gas poisoning (66.14%), electricity (63.30%) and fire (57.77%). The last three type of injuries were animal bite (21.13%), leisure or play (25.09%) and crime (33.28%). Analysis with multiple level model showed that family-related and householder-related factors had significant influence to home safety, such as the number of family members, square meters per person living, education years and type of occupation.Conclusion:1. Injury events were very common in community. Community based injury intervention should consider first the high risk population (the elderly, personnel working on manufacture, construction and transportation, children and adolescents) and high risk setting (city road/street, road within residential area, home and industry and construction field). The education and training on first aid should be part of basic education with concerned regulation and policy to guarantee the enforcement of this kind of education.2. Among people, vehicles and road/street which are three factors related to traffic accident the intervention priority should be put on people especially on drivers of motor vehicles and drivers of scooters. By making use of epidemiologic principles we may point at risk factors related to host, agent, vector and environment at different stages of injury event in order to find ways to reduce or eliminate those risk factors.3. Home injury and sport injury should be given priority in children’s injury prevention, especially in home establishments and sports protection. Children’s parents or care givers had misunderstanding in terms of injury prevention and intervention so more attention should be paid to them including nurserymaid.4. At the moment the injury surveillance system both at national and municipality level has not been well established yet a set of injury data resources can be useful for collecting injury data including household survey, injury report from community health center, and data from related government departments so that more completed injury situation and characteristics can be understood. However human and material resources must be considered too at the same time.5. Ecological model that is both individual-related factors and the physical and social environments that people live should be considered when we think about community injury intervention including education strategy and environment intervention strategy. Education strategy should be theory-based and environment improvement or renovation should be evaluation-based.更多还原