【作者】 崔颖；

【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， 2009， 博士

【摘要】 研究目的本研究旨在综合运用定性和定量研究方法，建立一套适合于西部地区村卫生室卫生服务能力实际情况、具有较高信度、效度和区分度并易于实际应用和推广的村卫生室卫生服务能力评价指标体系，为卫生行政部门和管理机构加强村卫生室卫生服务的科学化、标准化、规范化管理提供参考和依据。研究方法采用文献情报分析法、个人访谈、专题小组访谈、现场调查、Delphi专家咨询法用于建立指标体系，并采用模糊数学综合评判法计算指标权重系数；采用因子分析法、聚类分析和方差分析等数理统计方法进行指标体系的效度、信度和区分度的检验；运用综合指数法和加权Topsis法二种评价方法进行综合评价。研究内容(1)查阅和研究卫生服务评价基本理论、方法以及国内外相关研究成果，确立研究框架和结构；(2)采用专家咨询以及文献查阅等方法确定村卫生室基本服务项目和服务内容；(3)通过现场调查，了解西部地区村卫生室服务能力现状，发现存在的问题并提出相关政策建议；(4)通过运用专家访谈、专家咨询法以及现场调查等方法筛选并建立评价指标体系，计算指标权重；(5)运用综合指数法和加权Topsis法二种评价方法，对西部地区部分村卫生室进行综合评价，并运用Kendall协同系数检验法进行趋同性检验，验证评价指标的稳定性和指标体系的可操作性；(6)采用因子分析法、聚类分析和方差分析等数理统计方法评价指标体系的效度、信度和区分度；(7)建立标准化评价指标体系，形成可操作的评价手册。研究结果(1)通过专家咨询、重点知情人物访谈等方法，从服务条件、公共卫生服务、基本医疗服务和非医疗服务能力四个方面构建村卫生室服务能力评价指标体系，同时将每个一类指标按照不同层次分为三级。(2)一级评价指标中，服务条件包括设备设施、人力资源和财力资源3个二级指标以及二级指标下9个三级指标；公共卫生服务中包括妇幼保健、健康教育、疾病控制和协助工作4个二级指标以及二级指标下22个三级指标；基本医疗服务中包括常见病诊治、急诊急救及规范服务3个二级指标以及常见病、多发病诊疗知识考核合格比例、常见急症知识考核合格比例、处方书写规范率和基本药物占处方用药的百分比4个三级指标；非医疗服务能力包括反应性和满意度2个二级指标以及社区居民反应性和社区居民和村委会满意度2个三级指标。(3)通过专家咨询和Fuzzy综合评判法确定每级指标的权重。一级指标的权重值分别为0．243333、0．400833、0．261667、0．094167；二级指标的权重分别为0．100417、0．095000、0．047917、0．054615、0．145769、0．077308、0．081667、0．046667、0．116667、0．060833、0．084167、0．046667、0．047500。(4)对各二级评价指标进行因子分析，验证评价指标体系的结构效度。服务条件的二级指标因子分析结果显示，共提取3个公因子，其贡献率达到了76．355％。因子1受人员培训、人员数量和人员资质的影响，可看作服务条件中的“人力资源”；因子2受设备、房屋面积、房屋设置和药品数量的影响，可看作服务条件中的“设备设施”；因子3受上级经费投入的影响，可看作服务条件中的“财力资源”。同法对其他一级指标下属的二级指标进行因子分析，结果均显示因子分析的结果与一级评价指标预设的指标相近，表明指标体系设计在总体上具有较好的结构效度，内在结构基本稳定。(5)计算克朗巴赫α系数反映指标的内在信度。二级指标的克朗巴赫α标准值为0．82，三级指标的克朗巴赫α标准值为0．92，α值均大于0．7，指标的信度较高。(6)聚类分析结果显示，八个评价地区分成好、中、差三类较为合理，方差分析的结果也表明，三组之间以及每两组之间的差异在统计学上有显著意义(P＜0．05)，指标体系具有较好的区分度。(7)综合评价的结果显示各种评价方法结果比较趋同(协同系数W=0．5982，近似卡方值x~2=16．7500，p＜0．05)，说明了所筛选出的评价指标能用于西部地区村卫生室卫生服务能力评价。结论(1)村卫生室基本卫生服务项目和内容应贯彻预防为主的方针，开展农村地区常见病、多发病的初步诊治和公共卫生服务，满足农村居民卫生服务需求。(2)评价指标体系具有较为合理的结构，评价内容完整。(3)采用Delphi专家咨询法对评价指标进行筛选，结果较为可靠。(4)在专家评判的基础上，采用模糊评判方法计算指标权重，确保了计算结果的科学性、准确性和合理性。(5)指标体系具有较好的信度、效度和区分度，具备运用于实践的基本条件。(6)不同综合评价方法的结果具有较好的一致性，说明评价指标体系有较好的稳定性和可操作性，也说明评价指标体系能够用于对村卫生室卫生服务能力的评价。更多还原

【Abstract】 Research PurposesThis research is to use qualitative and quantitative methods to develop ancomprehensive and scientific evaluation indicator system with high validity,reliability anddifferentiation for evaluating health service capacity of village clinics in western areas ofchina,which is suitable for the current development situation of health services of villageclinics in western areas and easy to carry out and spread,and thereby provide reference andbasis for strengthening scientific,standardized and normalized administration of healthservices of village clinics for health administrative departments and organizations.Research MethodsIn this study,literature review and analysis,personal interview,group discussion,fieldinvestigation and Delphi method were used to develop the indicator system,and fuzzymathematical method was used to calculate the weight of the indicators.Factor analysis,cluster analysis and ANOVA analysis were adopted to test the validity,reliability anddifferentiation of indicator system.Comprehensive Indicator Method、Weighted Topsismethod,Grey Relation Analysis Method and Projection Pursuit Method were applied toevaluate the service capacity of the village clinics. Research Contents(1) To establish the basic framework of the research by reviewing the relevant theoryand methods of the health evaluation as well as some of relevant researches.(2) To determine the basic health service items and contents of the village clinics byusing Delphi method and literature review.(3) To understand the current status of the village clinics in western areas of China,andto find the existing problems and bring forward the suggestions by carrying out the filedinvestigation.(4) To select the indicators by using experts discussion and Delphi method and tocalculate the weight of indicators by using fuzzy mathematical evaluation method(5) to evaluate the service capacity of the village clinics by using ComprehensiveIndicator Method、Weighted Topsis method,Grey Relation Analysis Method and ProjectionPursuit Method and to verify the stability of indicators and operability of the evaluationindicators system by calculating Kendall’s coefficient of concordance.(6) to test the validity,reliability and differentiation of indicator system by selecting themethods of Factor analysis,cluster analysis and ANOVA analysis.(7) To develop the standard evaluation indicator system and form the operationalevaluation handbook.Research Results(1)An evaluation indicator system for health service capacity of village clinics in Chinais to be developed in four aspects of service conditions,public health services capability,basic medical services capability and non-medical services capability respectively,by meansof experts consultation,key informant interviews,etc.Meanwhile,each category ofindicator is to be classified into 3 classes according to its levels.(2)In class 1 evaluation indicators,3 class 2 indicators (equipment and facilities,humanresources,financial resources) and 9 class 3 indicators under class 2 indicators are included in service conditions;4 class 2 indicators (maternal and children health care,healtheducation,disease control,assistant work) and 22 class 3 indicators under class 2 indicatorsare included in public health services;3 class 2 indicators (diagnosis and treatment ofcommon diseases,emergency treatment,standard services) and 4 class 3 indicators (exampass rate of knowledge on diagnosis and treatment of common diseases andfrequently-occurring diseases,exam pass rate of knowledge on common acute diseases,rateof standard writing of prescriptions,the percentage of basic drugs to prescription drugs) areincluded in basic medical services;2 class 2 indicators (reactivity,the degree of satisfaction)and 2 class 3 indicators (reactivity of community residents,the degree of satisfaction ofcommunity residents and village committees) are included in non-medical servicescapability.(3)The weighting of each class of indicators is determined by experts consultation andFuzzy comprehensive judgment method.The weighting of class 1 indicators is 0.2433,0.4008,0.2617 and 0.0942 respectively.The weighting of class 2 indicators is0.100417,0.095000,0.047917,0.054615,0.145769,0.077308,0.081667,0.046667,0.116667,0.060833,0.084167,0.046667 and 0.047500 respectively.(4)Factor analysis to each two classes of evaluation indicators is made to test thestructural validity of the indicator system.The factor analysis of the second class indicatorsof Service Conditions showed that totally three common factors were extracted,theaccumulative variance reached 76.355%.The common factor 1 (F1) is mainly influenced byvariable“Number of village doctors per 1,000 population”,”Rate of holders of PracticingCertificate for Village Doctors”,”Rate of village doctors participated in trainings within twoyears”and“Exam pass rate of village doctors”and it could be named as Human Resources;F2 is mainly influenced by variable“Area of buildings for business”,”Arrangement ofbuildings for business”,”Rate of basic equipment equipped”and“Quantity and category ofdrugs”and it could be named as Equipment and Facilities;F3 influenced by variable“Amount of funds invested in village clinics by higher authorities”and it could be named as Financial Resources.The results of factor analysis are accordant with the expected resultsand it shows the indicator system has good validity.(5)The internal reliability of indicators is reflected by calculation of Cronbach’scoefficient a.The standard value of Cronbach’s coefficient a for class 2 indicators is 0.8193;the standard value of Cronbach’s coefficient a for class 3 indicators is 0.9179.The values ofa for class 2 and class 3 indicators are all larger than 0.7,indicating higher reliability ofindicators.(6)According to the cluster analysis,it is appropriate to divide the 8 evaluated districtsinto 3 groups,and the ANOVA analysis showed that the differences among the three groupsand between every two groups are statistical significant (P＜0.05) ,the differentiation of theindicators is good.(7)The results of evaluation showing relevant convergence of different evaluationmethods (coefficient of concordance w=0.5982,x2=16.7500,p=0.01) indicate that theseevaluation indicators can be used for health service capacity evaluation of village clinics andthe evaluation indicator system is relatively stable.Conclusions(1)The service items and contents of the village clinics should base on the preventivehealth service and carry out the basic medical health service for the rural residents to meettheir health service demands.(2)The evaluation indicator system has relatively reasonable structure as well asintegral and complete contents in evaluation.(3)The results are relatively reliable as evaluation indices are screened with Delphiexpert consultation method.(4)On the basis of judgment by experts,the weighting of indicators is calculated withFuzzy judgment method to ensure scientific,accurate and reasonable calculation results.(5)The indicator system has good validity,reliability and differentiation and it issuitable for evaluating the village clinics. (6)The results of different comprehensive evaluation methods shows the evaluationindicator system has good stability and operability,and also indicates that the evaluationindicator system developed can be used for evaluation of health service capacity of villageclinics.更多还原