【作者】 陈昊；

【导师】 张新平；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2010， 博士

【摘要】 目的研究教育干预的实践经验,研究国内外已有促进抗菌药物合理使用的教育干预活动设计、干预形式、干预资料和干预效果。在文献资料研究基础上,调查分析即将步入临床实习阶段前的高年级临床医学生对抗菌药物应用知识的的掌握情况,对抗菌药物使用的信念、态度,和在临床药物治疗学实践上的使用倾向；增加临床医学生对抗菌药物不合理使用危害的认识,促进其抗菌药物合理使用观念的树立和强化；提高临床医学生对抗菌药物合理临床应用指导原则的掌握,改善其用药认知,为临床医学生将来在从医行为中合理进行处方抗菌药物提供理论和实践基础；对促进临床医学学生抗菌药物合理使用能力提出建议,包括教学课程设置、教学方式、内容安排等,为我国临床医学本科教育增加药物治疗学内容的必要性建议提供参考依据。初步构建可稳定、有效适用于抗菌药物合理使用教育干预的实验模型。方法本研究选择湖北省内两所医学高校(分别为卫生部属华中科技大学同济医学院和湖北省属咸宁学院医学院)在校本科五年制临床医学专业4年级医学生,开展基线、干预结束及干预结束后一段较长时期(干预4个月后)的三阶段问卷调查,了解干预对象在各阶段的对抗菌药物合理使用的认知情况,评估干预效果。①设计：在两所医学本科院校(华中科技大学同济医学院和咸宁学院医学院)内展开关于抗菌药物合理使用知识方面的教育干预,采取自身前后对照的方法进行类试验研究；②干预方案：本研究选取国内医学院校内设置最普遍的五年学制本科临床医学专业四年级学生作为干预对象。干预对象已完成临床医学专业的基础医学阶段和临床医学理论教育阶段学习,即将步入临床专业实习阶段,即将接触、或在带教指导下见习、实习临床医师处方行为。针对干预对象开展两种方式共计三个类别(两种干预方式单独或组合)的教育干预,干预内容包括：(1)抗菌药物合理使用的知识培训,采用专家讲座的形式,内容上选择五年制临床医学本科教学体系内相对缺乏、与临床医疗实践联系紧密、应用频繁的有关抗菌药物合理使用知识,侧重抗菌药物合理使用的教育、管理,包括抗菌药物合理使用原则、适应症、不良反应、限制性使用措施等。(2)基于问题式的、围绕抗菌药物合理使用材料进行的小组专题讨论,学习材料内容上基于卫生部和国家药品监督管理局2003年联合印发的《抗菌药物合理使用100问》、《抗菌药物合理使用知识》两本培训材料制作的小组问题讨论稿。③资料收集和分析：本研究采用三阶段调查问卷的方式评价干预效果。在样本院校内对符合条件的干预对象进行整群抽样,在该年级选定300学生作基线调查；将300名学生随机分为三组,每组100人,分别接受单一方式干预：方案1(专家专题讲座)、方案2(基于文本材料的问题式小组讨论),和综合干预(方案1+方案2)并接受问卷调查；干预4个月后对前述3组进行二次问卷调查评估。调查问卷的主体内容包括知识、意识态度和行为三部分。对所收集资料采用如下方法来进行分析：问卷内各题均被统一转化成分数,按照得分越高、抗菌药物使用的合理性评分越高；依据得分对其进行描述性分析；知识得分整体分析、信念和行为逐条分析；分析干预前后知识、信念、行为分布是否有差异；分析不同干预方案横向对比差异；分析未接受教育干预、单一方式干预和综合干预样本在知识、信念和行为方面差异；分析不同地区、不同等级或规模医学院校在干预前和采用相同干预后的知识、信念和行为差异；分析其他因素对效果的影响。部分干预和综合干预均以基线调查数据作自身对照。结果1.研究在知识-信念-行为模型和理性行为理论以及行为逐渐改变理论等理论基础上构建了本次教育干预的理论模型：在长期、积累、持续的知识、结构变量(健康或疾病知识、自身或他人经历)和社会心理结构变量(性格、社会阶层等)的作用下,人意识到了问题的严重性；在特定的社会环境、具有一定知识背景、特定的人口学特征下,人们产生的信念决定了其意识和态度、主观准则和客观判断标准；在意识和信念共同作用下产生行动意图,在各种因素下对行动意图的影响不断强化,最终促使行为发生。2.基线调查发现,临床医学生对抗菌药物合理使用的知识掌握程度有限,两校样本医学生知识总体平均得分,同济医学院样本4.69分,咸宁医学院样本4.52分。知识各部分得分在两校间无差异,各院内性别间知识正确率无差异。意识和态度总体平均得分,同济医学院样本35.76分,咸宁医学院样本为36.24分,行为总体平均得分同济医学院样本总体平均得分为25.72分,咸宁医学院样本为25.90分,意识和态度及行为得分在两校内的性别间无差异,两校间总体平均得分之间也无差异(P均大于0.10)。知识与意识态度总体得分之间、知识与行为总体得分之间、意识态度与行为总体得分之间均不构成回归关系。3.干预后,在三种干预方案下,被干预对象的知识、行为总体得分在干预前后有显著性差异,但意识和态度方面的改变却均无统计学意义。干预后间隔3个月时间先后进行的两次问卷调查结果,知识、意识态度或者行为校正平均得分均未表现出统计学差异。4.专家专题讲座(方案一)、基于问题式的小组讨论(方案二)和兼用以上两种方式(方案三)开展的三种教育干预手段,在医学生的抗菌药物合理使用知识掌握上均可显著性影响总体平均知识得分,干预前后得分率的差别具有统计学意义。方案一与方案二、三之间均存在显著性差异(P<0.001),但二、三之间无显著差异(P>0.10)。以逐条问题判断,三种不同方案对意识、态度干预前后结果无差异(P>0.25)；对行为部分,三种方案在干预前后均有显著差异(P<0.001),而三种干预方案间两两比较有差异,但差异不显著(0.10＜P＜0.20、0.40<P<0.50及P>0.50)结论虽然高年级临床医学生在进入临床实习阶段前曾接受过《药理学》、《临床药理学》(选修)以及《内科学》中部分与药物治疗学内容相关的知识的训练,但临床医学生普遍表现出对有关抗菌药物合理使用的知识掌握差、知识老化、学习内容与临床实践脱节、存在错误的用药行为或判断的特点。本次针对临床医学专业高年级学生进行的临床前抗菌药物合理使用知识的教育干预,提高了临床医学生对抗菌药物合理使用知识的掌握,但对于增强医学生合理使用抗菌药物的意识,效果并不明显；在教育干预的方式上,抗菌药物合理使用专题讲座和基于问题式的小组讨论都能起到一定的效果,后者的短期效果和长期效果都比前者显著。医学生抗菌药物使用的知识与其意识、行为之间的并无明显的回归关系,本研究所构建的模型可解释此现象；临床医学的专业教育要重视医学生临床药物治疗学的内容,特别是抗菌药物合理使用方面的教育,同时必须将合理用药知识包括抗菌药物的合理使用等相关内容课程纳入到临床医学生的本科教育课程体系当中,并在教学中引入基于问题式的教学法,以期为其在未来的职业生涯中进行正确的处方行为打下良好的职业基础。创新性采用对照研究的方式研究、评价教育干预对促进高年级临床医学生抗菌药物合理使用的效果,相关研究在国内非常少见。其次,本研究在知识-信念-行为模式、理性行为理论、行为分阶段改变理论的基础上构建了一个相关教育干预理论模型,该模型弥补了经典的KAP模型在知识、信念、行为相互关系中简单串联关系的缺陷,以及KAP模型无法解释本次研究中所表现出的三者间无明显相关关系的结果。该模型具有一定的稳定性,验证并可解释本次研究的结果。本研究选择未来的处方者——高年级临床医学生作为干预对象进行宣教,是将WHO促进合理用药的核心政策在促进抗菌药物的合理使用上的具体应用,具有现实意义,国内尚无同类型研究；将“基于问题的小组讨论”式的教育方式结合专题讲座的形式对医学生抗菌药物合理使用知识进行干预,是PBL教学模式在药物治疗学教育上的具体尝试,国内亦尚无相关报道；本研究采用效度较高的干预设计方法,采用基线调查作空白对照、干预前后独立调查及干预后不同时间点进行2次调查,纵向和横向对比的方法,在国内本领域的研究具有创新性。更多还原

【Abstract】 ObjectiveSurvey the clinical medical students’current knowledge and understanding of rational use of antimicrobial and promote rational use of antimicrobials,which are achieved through mastering knowledge and information, increasing awareness and enhancing the attitudes, hastening the behaviors of clinical medicine students. Conduct a stable model for educational intervention to promote rational use of antimicrobials.Subjects and MethodsExperiment DesignTwo parallel educational interventions at Xian-ning medical college and Tongji Medical College of Huazhong University of Science and Technology, pre-post self-comparison which always are regarded as quasi-experiments were performed.InterventionStudents majoring in clinical medicine at grade 4 in two colleges were selected as the observed subjects. Three kinds of different educational interventions were conducted in a month, and the main educational content were the hazards of irrational use of antimicrobials, the principles of rational use of antimicrobials(RUA), good prescribing antibacterial medicines for infectious diseases and somethings on. The educational interventions were performed in 3 different ways which included taking the courses of lectures about RUA, discussion in groups in the way of problems-based-learning and both above.Data collection and analysis The intervention effects was evaluated by a sieries of questionnaire surveys. Subjects were chosen by stratified random sampling in two college in which every 70-100 students were put into each three groups in both. Datas were sampled three times, the first one as the baseline was adopted before the intervention and the second one right after the intervention and the third later after 3 months respectively. The questionnaire covered three main fields:knowledge, awareness and attitudes, and behaviors of RUA. Data were collected and analyzed in the following way:At first, data were scaled by scores according to a standard and desriptively analyzed, the higher it scored, the more RUA existed. For each knowledge item, differences of genders, family total incomes or the burden ways for the healthcare charge in correct rates was tested byχ2 test, and differences among scores concerning awareness and attitudes, were analyzed by t-test and variance analysis,and also behaviors did in same way. The effect of educational intervention on overall scores of knowledge was done by covariance analysis with factors above as covariates, the performance of each item of awareness and attitude, behavior were dilcoxon singned-rank test and rank sum test. Also Kruskal-Wallis H test was done to compare the effects of three typies interventions.Results1. A new model suit for certain type of educational intervention was structed in this study based on some theories or models include of KAP (Knowledge-Attitude-belive-Practice)model and TRA and some else. Influnted by the longlasting and effective variable parameter of the society and mental factors and accumulated knowledge and clues, an awareness of the susceptivity and severity arises; Under certain knowledge background, social circumstance and else demographic characters, a belief including ubjective criterion and abojective judgement standards generates, the belief would determine the attitude. Affected by the former two aspects combined, intention was formed, and with graduatedly being streghened by all kinds of infactors, the real action was persued.2. At baseline, clinical medicine students showed very poor knowledge of RUA, with total average scores 4.69 for Tongji group and 4.52 for Xianning group; There were no statistical discrepancy between both genders and both two colleges. There was no regression relationship between the knowledge and the attitude or behavior, also between the attitude and behavior.3. After the execution of the three typies of educational interventions, the average scores of knowledge, of clinical medicine students did improve in all six groups, but the change of the scores of awareness and attitude did not made difference statistically. The scores of knowledge and behavior made difference statistically significal while the attitude did not. Three different interventions made signifcal difference in changing the levels of knowledge and behavior, but did not affect the score of the attitude. There were no statistical difference between the two surveys with 3 interval months in all three parts of the questionnaire survey.4. All three typies interventions could affect the total average scores of the knowledge. There were significant differece between the intventions of courses of lectures and grouped-discussion in PBL way or both two combined. With Wilcoxon singned rank test and rank sum test, there were statistically significal difference in judging the change levels of the behavior but not with the attitude parts.5. A stable model for educational intervention to promote rational use of antimicrobials was estabished which could explain the results of the research.Conclusion1. Clinical Medicine students have limited knowledge of the rational use of antimicrobials, also have some wrong attitute and awareness around RUA, which lead to misuse of the antimicrobials.2. In the study, the three typies of educational interventions executed in the medical college did have some positive effects on enriching medical students’knowledge and promoting their behaviors on rational use of antimicrobials.3. There were no regression relationships between the knowledge and the awareness or the behavior on rational use of antimicrobials of the medical students.4. More attention should be paid to medical students’education on rational use of antimicrobials. Meanwhile, courses based on RUA must be merged into the curriculum for medical students in the way of PBL.InnovationThe educational intervention method based on the PBL were seldom adapted to study the effect of promoting rational use of antimicrobials among clinical medicince students in China; and a new model suitable for certain type of the educational intervention was established on the basic of KAP, TRA(Theroy of Reasoned Action) and HBM(Health Belife Model), and other models. The model got a comparative stability and excellently interpreted the result of this study.更多还原