【作者】 张梅；

【导师】 王静；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2024， 博士

【摘要】 【目的】农村慢性病防控是现阶段我国医疗卫生服务的重点和难点,受到国家和社会的广泛关注。家庭医生团队作为慢性病防控的主要提供者,其团队协作程度对慢性病防控效果发挥重要影响。然而,目前家庭医生团队在协作基础、协作程度及与患者行为的关系并不清晰,对慢性病防控效果的影响机制有待研究。因此,本研究从协同治理理论的核心理念出发,以家庭医生团队协作为切入点,从家庭医生团队协作基础、家庭医生团队协作程度、患者健康行为和患者防控效果四个维度构建农村家庭医生团队协作对慢性病防控效果影响的理论框架,探究影响家庭医生团队协作的内在逻辑及其影响农村慢性病防控效果提升的关键因素和主要路径。为改善农村家庭医生团队协作提供有效的理论依据,同时也为提升农村慢性病防控效果提供政策参考。【方法】本研究运用定性和定量相结合,理论分析与典型案例剖析相结合的方法,探究家庭医生团队协作对农村慢性病防控效果的影响机制。具体方法包括:(1)理论模型构建方面,基于文献研究和理论分析构建了家庭医生团队协作对农村慢性病防控效果影响的理论模型。在此基础上,结合专家研讨,设计了农村地区家庭医生团队协作基础、协作程度、患者健康行为及患者防控效果的测量指标体系;(2)现场调研方面,采用多阶段分层随机抽样方法,在中西部A、B两县,先抽取乡镇,再从中抽取行政村,进行现场调查。最终共获取688份农村慢性病患者问卷,以及相对应的72个家庭医生团队的综合数据和317份家庭医生团队成员问卷,并收集了73份关键知情人访谈资料;(3)影响机制分析方面,采用多元线性回归对农村慢性病防控效果的影响因素进行了初步分析,进而采用跨层中介模型检验了前期构建模型的研究假设,识别了具有统计学意义的影响路径;(4)质性研究方面,采用主题框架分析法对访谈资料进行系统编码与分类,基于地方实践的现实情景归纳提炼出典型影响机制,并遵循“前因-过程-结果”逻辑,深入剖析家庭医生团队协作对农村慢性病防控效果的作用机理。【结果】研究发现,家庭医生团队协作基础是提升慢性病防控效果的关键,而家庭医生团队协作程度与患者健康行为的联合作用对提升慢性病防控效果显著。这些影响机制还存在区域差异。此外,结合定性分析结果,可将慢性病防控效果的典型影响机制可分为“关系互动型”、“制度导向型”和“领导参与型”。具体研究发现如下:(1)在探究家庭医生团队协作基础与慢性病防控效果关系时发现,家庭医生团队协作起始资源(β=0.444,P<0.01)、制度设计(β=0.325,P<0.05)和催化领导(β=0.420,P<0.01)对慢性病患者治疗效果有显著正向影响。(2)在分析影响机制时发现,患者预防行为与团队协作程度在团队起始资源与慢性病治疗(β=0.039,P<0.05,占总效应12.11%)和预防效果(β=0.045,P<0.05,占总效应16.54%)关系中发挥链式中介作用;制度设计通过团队协作程度和患者治疗行为的链式中介作用,对治疗效果(β=0.031,P<0.05,占总效应14.98%)与预防效果(β=0.037,P<0.05,占总效应24.34%)产生显著影响。此外,制度设计还通过团队协作程度和患者预防行为的链式中介,对慢性病治疗效果(β=0.041,P<0.05,占总效应19.71%)和预防效果(β=0.048,P<0.01,占总效应31.79%)产生显著影响;团队催化领导通过增强团队协作程度和引导患者治疗行为,对慢性病治疗效果(β=0.043,P<0.1)和预防效果(β=0.050,P<0.1)展现出边缘显著的积极影响。同时,催化领导通过团队协作程度和患者预防行为的链式中介,显著影响慢性病治疗效果(β=0.064,P<0.05,占总效应18.34%),并在预防效果上边缘显著(β=0.050,P<0.1)。(3)在地区间比较时发现,A县患者主动健康行为在团队起始资源与治疗(β=0.167,P<0.05,占总效应39.29%)和预防效果(β=0.262,P<0.01,占总效应66.50%)间呈正向效应;患者治疗行为在催化领导与治疗效果间表现出显著正向影响(β=0.148,P<0.05,占总效应40.11%)。而B县,团队起始资源通过团队协作程度和患者预防行为的链式中介作用边缘显著影响慢性病预防效果(β=0.059,P<0.1);团队制度设计通过团队协作程度和患者预防行为的链式中介作用,显著影响慢性病预防效果(β=0.049,P<0.05,占总效应16.55%)。患者预防行为在催化领导与预防效果之间发挥中介作用(β=0.178,P<0.05,占总效应41.78%)。(4)在对质性研究结果归纳时发现,家庭医生团队协作对慢性病防控效果影响存在三类典型机制。第一,是“关系互动型”影响机制,其典型特征是通过家庭医生与慢性病患者之间的“关系互动”,深化医患之间的信任,来提升患者预防行为依从性,进而实现慢性病预防。第二,是“制度导向型”影响机制,即通过优化家庭医生团队服务资源配置以及完善绩效考核体系,以相关制度为抓手,保障团队协作机制的高效及可持续性。第三,是“领导参与型”影响机制,强调通过领导力增强家庭医生团队服务凝聚力和执行能力,提升患者的预防行为依从性,进而影响患者治疗效果。【结论】(1)慢性病防控效果受到团队协作基础的影响。充足的物质资源和合理的运行机制是团队协作基础的关键要素。为此,优化家庭医生团队协作的基础成为提升防控效果的关键。优化过程不仅要“保障资源的投入”,还要“强化机制的设计”。(2)家庭医生团队协作基础通过患者行为间接影响慢性病防控效果,这可能与家庭医生团队与患者间的医患互动和角色互补有关。未来应以“医患价值共创”为核心导向,构建医患间良性互动循环,推动慢性病管理的可持续发展。(3)开展家庭医生团队服务可能存在基于资源禀赋的差异。家庭医生团队服务需因地制宜,灵活调整策略。在资源有限区,应着重改善医患关系,巧用非物质资源与信息技术;在资源充裕区,则应强化激励机制与协作,提供创新服务以确保服务的高质量与连续性,进而综合提升慢性病防控效果。(4)面对当前慢性病防控体系存在的问题,如关系不紧密、制度标准模糊及领导力不足,未来应从加强医患互动、完善制度设计与强化领导力三方面着手,构建一个高效、协同的慢性病防控体系。【创新与不足】(1)研究创新:一是以协同治理理论为基础,探讨家庭医生团队协作对农村慢性病防控效果的影响,并逐步引入慢性病创新照护模型,进一步考虑患者健康行为的作用。通过这一过程,构建了本研究的理论框架。二是运用跨层中介模型验证了农村慢性病防控效果的影响机制,并结合质性研究归纳总结出“关系互动型”、“制度导向型”及“领导参与型”三种典型类型的影响机制。(2)研究不足:一是样本范围的地域局限,集中于A、B两县。虽然深化了对慢性病防控效果特性的理解,但可能约束研究发现的普适性和推广力。二是由于从客观指标反映慢性病控制效果通常需要较长周期,而本研究的测评周期较短,难以通过客观指标的变化来充分反映慢性病控制效果。因此,本研究采用了患者主观感知的方法来评价慢性病患者防控效果,这种方法虽能及时捕捉到患者对服务的感受和满意度,但在一定程度上存在局限性。三是尽管当前的研究已初步揭示了慢性病健康管理的关键影响机制,但在真实世界的复杂环境中,仍存在诸多潜在的影响因素,它们的影响力与作用方式尚未得到充分的探究和理解,有待进一步的研究。更多还原

【Abstract】 [Objective]Chronic disease prevention and control in rural areas of China at this stage is the focus and difficulty of healthcare services and has received extensive attention from the state and society.As the main executors of chronic disease prevention and control,the degree of collaboration of the family doctor team is crucial to the effect of chronic disease prevention and control.However,the current basis for the cooperation of family doctor teams,the degree of cooperation and its association with patient behavior are unclear,and the mechanism of the impact on the effectiveness of chronic disease prevention and control needs to be studied in depth.Therefore,this study takes the core concepts of collaborative governance theory as the starting point,takes family doctor teamwork as the entry point,and constructs a theoretical framework from four dimensions:the basis of family doctor teamwork,the degree of cooperation of family doctor teams,patients’health behaviors,and patients’prevention and control effects,to explore the internal logic of the impact of family doctor teamwork on the effectiveness of prevention and control of chronic diseases in rural areas as well as its key factors and main paths.The identification of key factors and main pathways affecting the improvement of chronic disease prevention and control effects provides a strong theoretical support for optimizing rural family doctor teamwork,and also provides a reference basis for policy formulation to improve the effectiveness of chronic disease prevention and control in rural areas.[Methods]This study uses a combination of qualitative and quantitative methods,theoretical analysis and typical case dissection to explore the mechanism of the impact of family doctor teamwork on the effectiveness of chronic disease prevention and control in rural areas.Specific methods include:(1)In terms of theoretical model construction,the theoretical model of the influence of family doctor teamwork on the effect of rural chronic disease prevention and control was constructed based on literature research and theoretical analysis.On this basis,the measurement index system of the basis of family doctor teamwork,the degree of collaboration,patients’health behaviors and patients’prevention and control effects in rural areas was designed by combining with experts’seminars;(2)For the on-site research,a multi-stage stratified random sampling method was used to conduct an on-site survey in two counties,A and B,in central and western China,from which townships and then administrative villages were selected.A total of 688questionnaires for rural chronic disease patients were eventually obtained,as well as the corresponding comprehensive data of 72 family doctor teams and 317 questionnaires for family doctor team members,and 73 key informant interviews were collected;(3)In terms of the analysis of influence mechanisms,multiple linear regression was used to conduct a preliminary analysis of the factors influencing the effectiveness of rural chronic disease prevention and control,and then a cross-level mediation model was used to test the research hypotheses of the preconstructed model and identify statistically significant influence pathways;(4)For qualitative research,the interview data were systematically coded and classified using thematic framework analysis,typical influence mechanisms were summarized and refined based on the real-life scenarios of local practice,and the“antecedents-process-results”logic was followed to analyze in depth the mechanism of the effect of family doctor teamwork on the prevention and control of chronic diseases in rural areas.[Results]It is found that the foundation of family doctor team is the key to improve the effectiveness of chronic disease prevention and control,while the degree of collaboration of family doctor team and the joint effect of patients’health behaviors are significant to enhance the effectiveness of chronic disease prevention and control.Combined with the results of the qualitative analysis,the typical mechanisms of chronic disease prevention and control effects can be categorized into"relational interaction type","system-oriented type"and"leadership participation type".In addition,there are regional differences in these mechanisms.The findings of the study are summarized below:(1)When exploring the relationship between the foundation of the family doctor team and the effectiveness of chronic disease prevention and control,we found that the activation resources(β=0.444,P<0.01),institutional design(β=0.325,P<0.05),and catalytic leadership(β=0.420,P<0.01)of the family doctor team had a significant positive impact on the effectiveness of treatment for patients with chronic diseases.(2)In the analysis of the mechanism of influence,it was discovered that patients’preventive behaviors and the degree of team collaboration play a chain-mediating role in the relationship between team initial resources and chronic disease treatment(β=0.039,P<0.05,accounting for 12.11%of the total effect)and preventive outcomes(β=0.045,P<0.05,accounting for 16.54%of the total effect).Institutional design,through the chain-mediating effect of the degree of team collaboration and patients’treatment behaviors,significantly impacts treatment outcomes(β=0.031,P<0.05,accounting for 14.98%of the total effect)and preventive outcomes(β=0.037,P<0.05,accounting for 24.34%of the total effect).Furthermore,institutional design significantly influences chronic disease treatment outcomes(β=0.041,P<0.05,accounting for 19.71%of the total effect)and preventive outcomes(β=0.048,P<0.01,accounting for 31.79%of the total effect)via the chain-mediating effect of the degree of team collaboration and patients’preventive behaviors.The catalytic leadership of the team,by enhancing the degree of team collaboration and guiding patients’treatment behaviors,exhibits marginally significant positive effects on chronic disease treatment outcomes(β=0.043,P<0.1)and preventive outcomes(β=0.050,P<0.1).Concurrently,catalytic leadership significantly influences chronic disease treatment outcomes(β=0.064,P<0.05,accounting for 18.34%of the total effect)and marginally significantly impacts preventive outcomes(β=0.050,P<0.1)through the chain-mediating effect of the degree of team collaboration and patients’preventive behaviors.(3)When comparing between regions,it was found that patient-initiated health behaviors in County A showed a positive effect between team-initiated resources and treatment(β=0.167,P<0.05,accounting for 39.29%of the total effect)and preventive effects(β=0.262,P<0.01,accounting for 66.50%of the total effect);and that patient-treated behaviors demonstrated a significant positive effect between catalytic leadership and treatment effects(β=0.148,P<0.05,40.11%of the total effect).In contrast,in county B,team starting resources significantly influenced chronic disease prevention outcomes through the chain-mediated edge of the degree of teamwork and patient prevention behaviors(β=0.059,P<0.1);and team system design significantly influenced chronic disease prevention outcomes through the chain-mediated edge of the degree of teamwork and patient prevention behaviors(β=0.049,P<0.05,16.55%of the total effect).Patient preventive behaviors mediated the link between catalytic leadership and prevention effect(β=0.178,P<0.05,41.78%of total effect).(4)In summarizing the results of the qualitative study,it was found that there are three typical mechanisms for the impact of family doctor teamwork on the prevention and control of chronic diseases.The first is the"relational interaction"mechanism,which is typically characterized by deepening the trust between doctors and patients through the"relational interaction"between family doctors and patients with chronic diseases,in order to improve the patients’adherence to preventive behaviors and thus achieve chronic disease prevention.Secondly,it is the"system-oriented"influence mechanism,i.e.,through optimizing the allocation of resources for family doctor team services and perfecting the performance evaluation system,the relevant system is used as the gripping hand to ensure the efficiency and sustainability of the teamwork mechanism.Thirdly,it is the"leadership participation"influence mechanism,which emphasizes that leadership enhances the cohesion and execution ability of family doctor team services,improves patients’adherence to preventive behaviors,and then influences patients’treatment effects.[Conclusion](1)Chronic disease prevention and control effectiveness is influenced by the teamwork foundation,where adequate resources and a sound operational mechanism are pivotal.Optimizing the family doctor team’s groundwork is crucial for enhanced prevention and control efficacy,involving both"ensuring resource allocation"and"refining mechanism design".(2)The basis of family doctor teamwork indirectly affects the effectiveness of chronic disease prevention and control through patient behavior,which may be related to the interaction between doctors and patients and the complementary roles of family doctor teams and patients.In the future,we should take"value co-creation between doctors and patients"as the core orientation to build a benign interaction cycle between doctors and patients to promote the sustainable development of chronic disease management.(3)Family doctor services vary by resource availability,necessitating localized strategies and flexible adjustments.In resource-scarce settings,prioritize strengthening doctor-patient bonds and leveraging non-material assets and IT;in resource-abundant zones,enhance incentives,cooperation,offer innovative care,ensuring quality and continuity,to holistically boost chronic disease control effectiveness.(4)With regard to the problems of weak relationship,ambiguous system standards and insufficient leadership in the current chronic disease prevention and control system,the future should be strengthened by enhancing patient-doctor interaction,optimizing system design and reinforcing leadership,so as to build an efficient and coordinated chronic disease prevention and control system.[Innovation and Deficiency](1)Innovative points of the study:First,based on the theory of collaborative governance,we explored the impact of family doctor teamwork on the effectiveness of chronic disease prevention and control in rural areas,and gradually introduced the model of innovative care for chronic diseases to further consider the role of patients’health behaviors.Through this process,the theoretical framework of this study was constructed.Second,the influence mechanism of rural chronic disease prevention and control was verified by using the cross-level mediation effect model,and three typical types of influence mechanisms were summarized in the qualitative study,namely,"relational interaction type","system-oriented type"and"leadership participation type"."leadership participation type".(2)Limitations of the study:First,the geographical limitation of the sample scope,focusing on counties A and B may constrain the generalizability and replication of the findings,although it deepens the understanding of the characteristics of chronic disease control effects.Second,because reflecting chronic disease control effects from objective indicators usually requires a long period of time,while the measurement period of this study is short,it is difficult to fully reflect chronic disease control effects through changes in objective indicators.Therefore,this study adopted the method of patients’subjective perception to evaluate the prevention and control effects of chronic disease patients,and this method has limitations to a certain extent,although it can capture patients’feelings and satisfaction with the service in a timely manner.Third,although the current study has initially revealed the key influencing mechanisms of chronic disease health management,in the complex environment of the real world,there are still many potential influencing factors whose influence and modes of action have not yet been fully explored and understood,and need to be further researched.更多还原