【作者】 朱闵敏；

【导师】 王增珍；

【作者基本信息】 华中科技大学 ， 流行病与卫生统计学， 2013， 博士

【摘要】 我国是全球22个结核病流行严重的国家之一，结核病负担全球第二。流动人口肺结核是当前中国结核病控制的一大难题，病例发现不及时、肺结核患者跨区域流动是肺结核高治愈率背景下提高结核病控制质量的瓶颈。风险传播，是个体、群体以及机构之间交换有关风险的信息、意见和看法的互动过程。风险传播应用于临床医疗领域，主要是医患之间分享和讨论有关医疗服务或健康行为利弊的信息，在个体化风险信息的基础上进行沟通，帮助患者选择某项医疗服务或改变不良行为。本文在深圳市南山区采用风险传播，在双向沟通、患者充分知情、提醒及激励的前提下，调动肺结核患者的自主能动性，促进肺结核病例的发现、实现跨区域转诊患者治疗的延续性，尝试肺结核控制领域新难题的突破。第一部分普通人群肺结核风险认知和病耻感目的：风险认知是指人们对风险性质和严重程度的主观判断，是采取健康行为或改变不良行为习惯的重要动力；肺结核病耻感指因患肺结核经历过或者预期受到负面对待，而产生的被排斥、拒绝、责难、贬低以及羞耻、有罪的个体体验，也是一种社会现象，是患者延迟就诊和治疗不依从的重要影响因素。本部分将掌握居民对肺结核的风险认知和病耻感现状，为肺结核患者相关健康行为（接触者筛查、就诊、治疗等）干预提供基础。方法：通过分层抽样方法，对在社区健康服务中心就诊的492名非肺结核患者进行问卷调查。结果：调查对象肺结核相关知识知晓率为82.0%；肺结核严重性认知6.9分（1-10分范围，为调查的八种疾病/状况的中间水平）、可能性认知为3.1分（1-10分范围，排在倒数第三位），总风险认知为2.1分（1-5分范围，所有疾病/状况风险认知水平接近）；同时结果提示大众存在一定的乐观或侥幸心理，54.9%认为自己比别人患肺结核的可能性小。调查显示，肺结核外部病耻感22.6分（0-50分范围），主要表现为与肺结核患者保持距离；内部病耻感总分为20.8分（0-50分范围），其中“别人会避开我”、“配偶或男女朋友不会与我同住”、“别人会瞧不起我”以及“即使治好了找工作都很困难”为前四项；负面情绪（紧张、害怕和担心）得分为3.6分（1-5分范围）。研究表明，肺结核知识与内部病耻感、严重性认知正相关（r分别为0.11和0.13），与易感性和风险认知及外部病耻感无相关关系；外部病耻感与严重性认知正相关（r=0.14），与易感性和风险认知负相关（r分别为-0.21、-0.13）；而内部病耻感只与严重性认知正相关（r=0.18）；病耻感两部分之间正相关（r=0.52）；负面情绪与外部、内部病耻感正向中度相关(r介于0.37-0.43之间)，与严重性认知正向弱相关(r介于0.12-0.16之间)。结论：被调查的居民肺结核相关知识知晓率达到卫生部“十一五”结核病防治规划要求，对于肺结核的风险认知与对慢性疾病（艾滋病、心梗、高血压、糖尿病）、急性疾病或状况（禽流感、普通感冒、食物中毒）的水平相当，存在肺结核的病耻感和负面情绪。第二部分传染性肺结核患者密切接触者筛查风险传播干预目的：密切接触者筛查是主动发现肺结核患者的有效手段，但在我国不被重视。本部分将探讨实施风险传播综合干预对提高肺结核患者配合度，促进其密切接触者接受临床筛查、提高肺结核病例发现的作用。方法：以南山区2011年登记管治的15周岁以上的传染性肺结核患者（涂阳、培阳和涂阴空洞）为研究对象，以其登记管治月份为单位将其分为干预和对照组（285名患者参与，其中对照组135人，干预150人）；对照组则按照国家结核病控制指南实施常规筛查——接受门诊医师口头问询，督导医师不参与；干预组采用督导医师强化宣教、发放筛查预约单、短信提醒及经济激励等综合干预措施。结果：干预组病人调查阶段共识别623名密切接触者，平均每名患者4.2名，高于国家指南预期的3名（P<0.001）；风险传播干预组有密切接触者到位的患者比例为36.7%（55名），远高于对照组9.6%（13名）（OR=3.304，P=0.001）；平均每名患者密切接触者筛查数，风险传播干预及对照组分别为0.7和0.1（IRR=3.205，P<0.001）。经临床检查，干预组发现31名肺结核病例（其中2名临床确诊患者、29名结核菌隐性感染），对照组只发现了7名结核菌隐性感染；对于每名患者发现二代肺结核病例来说，两组差异具有统计学意义（0.2VS0.1，P<0.001）。患者中推荐密切接触者的意愿平均为72.3%，其中推荐家人筛查意愿最高（91.7%）；推荐密切接触者筛查障碍中，预期会丢失工作、其他人会远离自己及失去经济来源排在前三位。结论：通过督导医师强化宣教、发放筛查预约单、短信提醒及经济激励等干预措施促进了患者推荐其密切接触者接受筛查，提高了密切接触者识别和病例发现；患者内心耻辱感是影响患者推荐的障碍。在保障患者工作权、平衡患者隐私权与他人健康权等的前提下，如何有效开展流动人口密切接触者筛查，以及提高密切接触者配合度的措施，是今后进行研究的问题。第三部分流动人口肺结核患者跨区域转诊风险传播干预目的：跨区域转诊现象在确诊的流动人口肺结核患者中经常发生，容易造成患者治疗不规范甚至中断治疗，给肺结核控制带来很大困难；中国肺结核跨区域转诊率虽只有3%，却占据治疗效果不理想（死亡、治疗失败、丢失等）的一半。本部分将研究风险传播措施在提高流动人口肺结核患者治疗的连贯性与治愈率的作用。方法：以南山区内登记管治的流动人口肺结核患者为对象，采用干预前后对照类试验方法；2007年10月-2008年9月（干预前）采用全球基金《跨区域肺结核患者管理程序》的方法；2008年10月-2009年9月（风险传播干预一期），执行包括“以提高患者治疗依从性的强化健康教育和医患交流、治疗期强化监督、跨区域转诊协助及追踪和加强转入地密切联系”在内的综合干预；2009年10月-2011年9月（风险传播干预二期），在干预一期基础上加强对转入地结核病防治机构干预，建立了与全国绝大部分县市机构的QQ联络平台，实时与转入地联络（提醒对方落实转出患者的转诊追踪，与其工作人员交流“中国疾病预防控制系统-转诊管理”的操作），采用经济激励措施（转入地采取“代管”方式管理患者，则转给结核病防治机构代管病人管理费）。结果：南山区4年共管治流动人口肺结核患者2244名，总转出率为17.1%，其中干预一期、干预二期转出率分别为18.5%（110名）、16.1%（179名），与干预前转出率17.5%（94名）接近（P=0.439）。干预前，只有39.4%的患者离深时提前告知医务人员，干预一期上升到61.8%，二期达到86.5%，年均增幅为30.0%（P<0.001）；转诊到位率从51.1%提升到2011年的85.5%，年均增幅为18.7%；四年内重登率绝对值下降了69%，年均降幅为32.1%；转出患者治愈或完成治疗率从4.3%增长到59.8%，但低于流动人口患者整体治愈率（86.0%）。结论：跨区域转诊管理风险传播综合干预措施-强化健康教育与医患交流、疗程关键点监管、转诊协助及与异地结核病防治机构交流沟通，能提高流动人口肺结核患者治疗的连贯性与治疗效果，但是不能减少患者转诊的发生；需要加强对流动人口的关怀、减少肺结核患者的经济负担。创新性：1.以定量的方法测量居民肺结核风险认知和病耻感现状，并分析它们的相关性；2.应用风险传播方法针对肺结核防治的瓶颈问题——肺结核病例发现不及时、流动人口跨区域转诊——进行干预，并有一定的突破，如促进了传染性肺结核密切接触者筛查的实施、提高了病例早期发现数和实现了流动人口跨区域患者治疗的延续性。更多还原

【Abstract】 China is one of the22countries with higher-burden tuberculosis (TB) disease, thatranked second in the world. Today, floating tuberculosis population, untimely detection ofTB case sand cross-regional transferred TB case are considered big obstacles in TB controlof China, despite comparatively high TB cure rate has achieved.Risk communication is an interactive process of risk information exchange amongindividuals, communities and institutions; In the field of clinical medicine, riskcommunication is referred to that doctors share and discuss with patients about the pros andcons of medical services or health behavior, and help patients choose a medical service orchange unhealthy behaviors on the basis of individual risk information.In this research, based on the informed decision-making mode of risk communication (asused in the field of clinic medicine), we executed several trials in Nanshan District,Shenzhen city. Intervention such as strengthened counsel, intercommunication, wellinformed consent, reminder and incentives were adopted to increase the self-efficacy andself-initiative of TB patients, thus to promote the TB cases finding and to achievecontinuous of treatment among cross-regionally transferred TB patients.Part I Risk perception and stigma of TB among residentsObjective: Risk perception is the subjective judgment of the nature and severity of risk, which is an important driving force for people to change health behavior. And TB stigma ispatient’s sense (also a social process) of be excluded, rejected, blamed, belittled and ofshame and guilt, arising from negative treatment they have experienced or anticipated,which is one of the important factors causing patients’ treatment delay and non-compliance.In this part, we tried to grasp the residents’ risk perception of TB and stigma, thus toprovide scientific evidences for developing effective intervention to change healthbehaviors of TB patients (i.e, contact screening, visit doctors and medication, etc).Methods: Totally,492non-tuberculosis patients were investigated by questionnaire inthe community health service centers, using stratified sampling method.Results: The results showed that the awareness rate of TB knowledge was82.0%; theperceived severity of TB was6.9(scale1-10), which was at the intermediate level of theeight diseases/conditions surveyed; the perceived vulnerability was3.1(scale1-10), rankedlast third within those diseases/conditions; and the perceived threat (severity*vulnerability)was2.1(scale1-5), which was similar to that of all other diseases/conditions. There was anoptimistic bias towards TB among the residents, as54.9%of the residents thought that thepossibility of getting tuberculosis was lower than others. The survey showed that the scoreof external TB stigma was22.6(scale0-50), of which the most situation was keeping theirdistance from patients with tuberculosis. The internal TB stigma was20.8(scale0-50), ofwhich “others will avoid me”,“spouse or boy/girl friends will not live with me”,“otherswill look down upon me” and “it is very difficult to find job even after being cured” werethe first four situations. And the composite score of the negative emotion (stress, fear andworry) was3.6(scale1-5).We found that the respondents’ TB knowledge was positively related to internal stigmaand perceived severity (r=0.11and0.13), and had no correlation with perceivedvulnerability, perceived threat and external stigma. The external stigma was positivelyrelated to perceived severity (r=0.14), and was negatively correlated with perceivedvulnerability and threat (r=-0.21,-0.13, respectively), while internal stigma was onlyrelated to perceived severity (r=0.18). And all negative emotions were moderate positivecorrelated with both of internal and external stigmas (r varied between0.37and0.43), andweak positive correlated with perceived severity (r varied from0.12to0.16). Conclusion: The awareness rate of TB knowledge by the surveyed residents hasachieved the goal set by the Ministry of Health in the "Eleventh Five-Year" TB controlprogram. TB risk perception of the residents was the same as that of common chronicdiseases (AIDS, heat attack, hypertension, diabetes) and acute diseases or conditions (avianinfluenza, colds, food poisoning). And tuberculosis-related stigma and negative emotionsexist among them.Part II Risk communication intervention on close contact investigation of patientswith infectious TBObjective: Contact investigation (CI) is considered one of the effective case findingstrategies, however set low priority in China. In this part, we will appraise the effects of riskcommunication intervention on improving patients’ adherence, close contacts’ acceptationof clinic screen, and promoting TB case findings.Methods: We adopted an un-random controlled intervention on CI of patients whowere15year old and above and with infectious TB (smear positive TB, culture positive TBor TB with cavity on chest X-ray) registered in Nanshan District, Shenzhen City, China.The patients were clustered grouped, based on their registered month. A total of285patients had received either a routine CI (135patients)—queried by the clinic doctors, or acombined intervention (150patients) of health education, prompt mobile message reminder,and symbolic incentives. Meanwhile, we executed a questionnaires survey on patients’willingness and obstacles to refer their close contact(s).Results: Totally,623close contacts were identified during patients’ interview in theintervention group, namely an average of4.6close contacts per index case which washigher than three expected by the National Guideline (P=0.009). The proportion of patientswho referred their close contacts and at least one received TB clinic screen were36.7%(55patients) in the intervention group and9.6%(13patients) in the control group (P=0.001). After being referred by TB patients,109close contacts in the intervention group and19inthe control group had received TB screening, and most were household members. Thenumber of close contacts screened per index case in the intervention group was higher thanthat in the control group (0.7VS.0.1, P<0.0001). Finally,31TB cases (29latent TBinfections (LTBI) and two active TB cases) were found in the intervention group, and7LTBI in the control group (TB cases detected per index case:0.2VS.0.1, P<0.0001). Thewillingness of patients to refer close contacts was72.3%, and they were more likely to refertheir household members (91.7%); while anticipating job lost, others’ avoidance behaviorand lowing salary were the first three obstacles.Conclusion: The comprehensive risk communication interventions have encouragedpatients to refer their close contacts to receive TB screening. Furthermore, this interventionhas promoted close contacts identification and TB cases detection. Internal stigma is theone of the big obstacles hindering close contact referring by patients. How to guaranteepatients’ work right, and to balance patients’ privacy rights and others’ health rights need tobe further researched. More direct interventions should be adopted in future specifically forclose contacts to improve their compliance.Part III Risk communication intervention on cross-regional transferred TB patientsamong floating populationObjective: Cross-regional transference often occurs among the diagnosed floating TBpatients, causing irregular medication or even discontinuation of treatment, thus broughtgreat difficulties for TB control. This section will assess the effect of risk communicationinterventions on the treatment continuity and outcomes of TB disease among floating TBpatients.Methods: From October2007to September2008(Phase before the intervention), wemanaged transferred patients according to the program of "cross-regional tuberculosispatient management" by Global Fund fighting TB; and from October2008to September 2009(risk communication intervention Phase I), we used interventions consisting ofstandardized health education and patient-doctor communication, strengthened supervisionof treatment, cross-regional referral assistance, timely patient tracking, and cooperationwith other TB dispensaries; from October2009to September2011(risk communicationintervention Phase II), we added new interventions to establish more cooperation betweenTB dispensaries, besides of measures in Phase I: QQ contact platform were established withalmost all of TB dispensaries at the county or city level in China, achieving real-timecontact (i.e., to remind tracing of transferred patients, to share the experiences of how tooperate the subsystem of management of TB cross-regional transference in national diseaseprevention and control system, and so on); also economic incentives for TB dispensarieswere adopted to award the behavior of non-reregistering of transferred TB patients.Results: Within the four years,2244floating TB patients were registered in NanshanDistrict. The total transfer-out rate was17.1%, and it was17.5%(94) at the phase beforethe intervention,18.5%(110) and16.1%(179) at the phase I and phase II (P=0.439). Therate of patients who informed doctors before transferred-out was only39.4%, and it raisedto61.8%at phase I, and to86.5%at phase II, with an average annual increase of30.0%(P<0.001); The successful transfer-out rate increased from51.1%at pre-intervention phase to85.5%at phase II, with an average annual increase of18.7%; the absolute value ofre-register rate decreased by69.0percentage points within four years, which meant anaverage annual decline of32.1%; and the cured rate of the transferred-out patientsincreased from4.3%to59.8%, but less than that of whole TB patients (86.0%).Conclusion: The intervention improves patients’ adherence and enhancescollaboration between TB dispensaries, establishes more practical mechanisms, whichcould be useful for TB control in China. However, more efforts should be directed towardsimprovement of TB control among floating population, especially advocating the economicperspective.Innovation:1. We quantitatively measured the risk perception and stigma related to TB disease bya scale, and analyzed their relationships; 2. We adopted comprehensive risk communication interventions on two big obstaclesof TB control—untimely detected TB case and cross-regional transference of floating TBpatients, and we achieved some ice-breaks, such as promoted contact investigation ofpatients with infectious TB in the result of earlier TB case finding, and continuoustreatment of transferred floating TB patients.更多还原