【作者】 徐小军；

【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：本研究的目的为系统评价特定阶段医学生的合理用药知识、意识和行为水平；评价对患者期望对医学生处方行为的影响和医学生对患者期望的反应水平；并评价各种合理用药宣教干预方法对它们的效果；建立了相应的理论模型。从而探索出关于提高医学生合理用药能力以及正确面对患者期望方面的可行的和有效的建议和对策。方法：本研究的研究方法包括：文献研究法,主要为搜集与本研究相关的资料,对收集的资料按照性质进行分类汇总；专家咨询法,主要是咨询论证干预设计方案、宣传资料内容和问卷调查项目；现场干预法(准实验法),选择五年制临床医学专业4年级下学期本科学生300名,随机分组分为三组分别采用专家专题讲座、问题式小组讨论和综合干预法进行干预；现场调查法,在干预前1周,干预后1-2周内开展,干预后3个月分别采用设计的问卷进行三次调查。结果和结论：医学生的合理用药知识水平令人堪忧,合理用药意识水平一般,合理用药行为水平一般,患者期望对处方行为的影响一般,医学生对患者期望态度较欢迎,接受程度一般,解释程度较高。就本次合理用药宣教干预对提高医学生合理用药知识水平来说,从短期和长期看,均有效；从短期看,部分干预优于完全干预；从长期看,完全干预优于部分干预；从短期看,专家专题讲座法和问题式小组讨论法效果无差别,但均优于综合干预法；从长期看,综合干预法和问题式小组讨论法效果无差别,但均优于专家专题讲座法。就提高医学生合理用药意识水平来说,各种方法有一定效果,但均不理想；从短期和长期看,部分干预优于完全干预,但都不明显；从短期和长期看,问题式小组讨论法和综合干预法的效果均优于专家专题讲座法的干预效果,问题式小组讨论法的效果与综合干预法差异不明显。就改善医学生合理用药行为来说,各种方法有一定效果,但均不理想；从短期看,完全干预和部分干预干预效果无差异；从长期看,完全干预干预效果优于部分干预；从短期看,专家专题讲座法的效果优于问题式小组讨论法和综合干预法,问题式小组讨论发和综合干预法效果无差异；从长期看,专家专题讲座法的效果优于问题式小组讨论法和综合干预法,综合干预法效果优于问题式小组讨论法。就减少患者期望对医学生处方行为的影响来说,各种方法有一定效果,但均不理想；从短期看,完全干预和部分干预效果无差异；从长期看,在减少患者期望影响上,部分干预效果好；从短期和长期看,在减少患者期望的影响方面,效果由好到差依次为：问题式小组讨论法、综合干预法和专家专题讲座法。就改善医学生对患者期望反应来说,各种方法有一定效果,但均不理想；从短期看,完全干预和部分干预效果无差异；从短期看,完全干预和部分干预效果无差异；从长期看,完全干预效果好；从短期和长期看,效果由好到差依次为：专家专题讲座法、综合干预法和问题式小组讨论法。医学生合理用药知识水平得分与调查阶段、宣教干预方法、性别、家庭收入状况评价和实习开处方频评价率正相关,与干预组别和实习指导老师指导质量评价负相关。医学生合理用药行为水平得分与与调查阶段、宣教干预方法、生源地区、家庭是否参加城镇职工医保、家庭是否参加商业医保、自身健康状况评价、实习指导老师指导频率评价、实习指导老师指导质量评价和医学课程学习成绩的赋值正相关,与干预组别、家庭医保种类的赋值和合理用药知识得分负相关。患者期望对医学生处方行为影响水平得分与宣教干预方法、生源地区、家庭是否参加公费医疗、家庭是否参加城镇职工医保、看医院次数评价的赋值、合理用药知识得分、合理用药意识得分和合理用药行为得分正相关,与干预组别、家庭医保种类的赋值和家庭医学背景成员数量负相关。医学生对患者期望反应水平得分与宣教干预方法、家庭收入状况评价、家庭是否参加城镇职工医保、医学课程学习成绩的赋值和合理用药行为得分正相关,与干预组别和看医院次数评价的赋值负相关。医学生合理用药知识和意识之间的关系模型为：Y=2.799+0.346X-0.043X2+0.002X3；医学生合理用药知识和行为之间的关系模型为：Y=3.052-0.169X+0.020X2-0.001X3；医学生合理用药意识和行为之间的关系模型为：Y=0.227+1.490 X-0.220X2。建议：加强医学生合理用药知识的教育,包括抓紧建立医学生合理用药知识课程体系,合理安排开展医学生合理用药知识教育教学,认真开展合理用药知识课程的考核与评估；重视医学生合理用药意识的培养,包括将合理用药意识的教育贯穿于整个高等医学课程教育中,将合理用药意识的教育贯穿于医学院校的整个校园文化建设中,将合理用药意识的培养作为临床实习的一个重要的目标；加强医学生合理用药行为的塑造,包括端正临床实习医院的医生用药行为应放在首位,提高临床实习带教老师的合理用药水平,加强对医学生临床实习中的合理用药行为的指导；加强对医学生正确面对与处理患者期望的引导,包括将医学生临床实习环节放在更重要的位置,增加医学生参与接诊病人的机会,加强对医学生面对与处理患者期望的指导。创新与不足：创新包括选取的干预对象有突破性,定量地评价了特定阶段医学生的合理用药知识、意识和行为水平,对指导我国高等医学教育具有重要意义；从卫生服务供方的角度定量地对患者期望对医生处方行为的影响和医生对患者期望的反应进行了评价,具有重大意义；系统全面地比较了所设计的各种宣教干预方法的效果,对以后相关宣教干预实践的开展具有重要的参考借鉴价值；通过多元线性回归和曲线拟合的方法建立了相应的理论模型,具有重要的应用价值和学术价值。不足包括所设计的干预方案与后期进行有一点差距；在对患者期望对医生处方行为的影响和医生对患者期望的反应上,只是从卫生服务供方的角度来进行研究,未从卫生服务需方的角度进行研究,还不够全面。更多还原

【Abstract】 Objectives:The study is to evaluate medical students’ rational drug use knowledge, awareness and behavior levels in specific stage, to evaluate medical students’ prescribing behavior effects induced by patients expectations and their response to patients expectations and to evaluate the effect of rational drug use propaganda intervention on them, also to establish the corresponding theoretical model. Thereby,to explore viable and effective suggestions and strategies to improve the medical students’ ability on rational drug use and correctly facing the patients expectations.Methods:The method in the study includes:literature research, which means primarily gathering related information about this study and then sort and aggregate them according to the nature of. Expert consultation, which is to consult experts intervention design, contents of promotional materials and investigation item in questionnaire. Field intervention method (quasi-experimental method), which means selecting 300 4-Semester undergraduate students who major in five-year clinical medicine first, and then dividing them randomly into three groups and use experts lectures intervention, group discussions intervention and comprehensive intervention to each group respectively. Field investigation,which means investigating to the students by the designed questionnaire one week before the intervention, one to two weeks after the intervention and three months after the intervention respectively.Results and conclusions:The level of medical students’ rational drug use knowledge is worried, the level of awareness in rational drug use is general,the level of rational drug use behavior is general and patient expectations’ impact on the prescribing behavior is general, medical students are open to patient expectations, accept neither more nor less and explain very much.As far as the interventions to improve the rational use of medical students knowledge of rational drug use, they are valid regardless of the long term or short term. In the short term, part intervention is better than full intervention, in the long term, full intervention is better than part intervention. There are no differences between expert lecture and problem-group discussion, which are also better than comprehensive intervention in the short term, there is no differences between comprehensive Intervention and problem-based group discussion, which are also better than expert lecture in the long term.As far as the interventions to improve the level of medical students’awareness of rational drug use, each method has some effect, but no one is very good. Part intervention is better than full intervention but not so significant in the short and long term, problem-based group discussion and comprehensive intervention are better than expert lecture intervention, in which their difference is not significant in the short and long termAs far as the interventions to improve the level of medical students’behavior rational of drug use, each method has some effect, but no one is very good. In the short term, there is no difference full and partial intervention, in the long term, full intervention is better than part intervention, in the short term, experts lecture is better than the problem-group discussion and comprehensive intervention, problem-group discussion and comprehensive intervention made no difference for the effect; in the long term, expert lecture is better than the problem-group discussion and comprehensive intervention, comprehensive intervention is better than problem-group discussion.As far as the interventions to reduce the impact of patient expectations to medical students’ prescribing behavior, each method has some effect, but none is very good. There is no difference between full intervention and part intervention in the short term. Part intervention is more effective in reducing the impact from patient expectations in the long term. In reducing the impact from patient expectations, the methods from good to bad is as follows:problem-group discussion method, comprehensive intervention and expert lecture.As far as the interventions to improve the level of medical students’response to patient expectations, each method has some effect, but no one is very good. There is no difference between full intervention and part intervention in the short term but in the long term full intervention is better. The Effect of the methods from good to bad is as follows:expert lecture, comprehensive intervention and problem-group discussion in the short term and the long term.The score of medical students’ rational drug use knowledge correlates to the investigation stage, educational intervention, gender, family income assessment and evaluation of practice prescribing frequency positively and at the same time correlates to intervention group and the quality evaluation of their instructor’s practice guide negatively. The score of medical students’rational drug use behavior correlates to the investigation stage, educational intervention, student’s area, the family whether to participate in urban workers medical insurance or not, the family whether to participate in commercial health insurance or not, self-assessment of health status, the frequency evaluation of instructor’s practice guidance, academic quality evaluation of internship instructor guide and medical course positively, also correlates to intervention groups, family health insurance category and rational drug use of knowledge score negatively. Patient expectations impact on medical students’ prescribing behavior correlates to educational intervention, student’s area, the family whether to participate in free medical care or not, the family whether to participate in medical insurance for urban workers not, the evaluation of frequency to hospital, score of rational drug use knowledge, score of awareness of rational drug use behavior and score of behavior of rational drug use positively, also correlates to intervention group, family health insurance type and number of family members with medical background negatively. The score of medical students’ response to patient expectations correlates to educational intervention, assessment of family income, family whether to participate in medical insurance for urban workers or not, medical courses’ assessment and score of rational drug use behavior, also correlates to intervention group and the frequency to hospital.The model about the relation between medical students’ rational drug use knowledge and awareness is:Y=2.799+0.346 X-0.043X2+0.002X3,The model about the relation between medical students’ rational drug use knowledge and behavior is Y=3.052-0.169X+0.020X2-0.001X3’ The model about the relation between medical students’rational drug use awareness and behavior is Y=0.227+1.490 X-0.220X2。Suggestions:Strengthening medical students’rational drug use knowledge, including establishing rational drug use knowledge curriculum, reasonable arrangements for rational use of knowledge in medical education and attaching importance to evaluation of rational drug use courses. Besides this, we must attach importance to bring up students’awareness of rational drug use, including developing rational drug awareness education programs throughout the higher medical education, putting drug awareness education throughout the construction of the campus culture and putting training of rational use of drug awareness as an important target of clinical practice. Also, medical students’rational drug use behavior should be reinforced, which includes correcting medication practice behavior of doctors at frist, improving the level of practice teachers’ rational use drug, strengthening the guidance of rational drug use behavior to medical students’ in clinical practice. The rest, strengthening the guidance about medical students’ correctly handling the patient expectations need in treatment, including putting clinical practice in a more important location, giving more opportunity to students to contact with patients and strengthening guidance to students about dealing with patient expectationsInnovations and limits:The innovations of this study is as follows:Firstly,the intervention objects selected is a breakthrough and evaluate the level of medical students’ rational drug use knowledge, awareness and behavior quantitatively, which is of great significance for our higher medical education. Secondly, this study give qualitative analysis of impact about doctors’ prescribing behavior from patient expectations and doctor’s response to patient expectations from the perspective of health services supply, which is of great significance. Thirdly, this study made a systematic and comprehensive comparison on effect of different educational interventions designed, which can give reference to related study of educational intervention later on. The corresponding theoretical model by multiple linear regression and curving estimation has important applications and academic values. Surely, this study has some limits, such as there is a gap between designed intervention programs and its implement. Besides this, the analysis on doctors prescribing behavior from patient expectations’ impact and doctors’response to it, is just from the perspective of health services supply, not from the perspective of health services demand, which is not comprehensive enough.更多还原