【作者】 张妍；

【导师】 周维谨； 刘晓瑷； 车焱；

【作者基本信息】 复旦大学 ， 流行病与卫生统计学， 2008， 硕士

【摘要】 【背景】我国自全面推行计划生育以来,取得了举世瞩目的成就,但在一段时间内和一定程度上忽视了计划生育的服务质量。1994年开罗国际人口与发展大会后,我国政府制定了有利于社会经济和人口发展的方针、政策、措施,形成了综合治理人口问题的基本思路。1995年,国家人口和计划生育委员会提出了计划生育工作要实现“两个转变”和“优质服务”,提出了要在科学合理的基础上,对计划生育服务进行规范化管理。我国各地区间人口和经济发展不平衡,中西部欠发达地区如何在稳定低生育水平的前提下开展规范化的计划生育优质服务成为新的课题。【目标】了解中西部农村地区育龄妇女对计划生育技术服务的满意度,分析满意度的影响因素及不满意的原因;评估技术服务质量现状及其与优质服务的差距并了解影响技术服务质量的因素,为后续干预提供依据。【方法与内容】本研究应用流行病学现况调查的研究方法,借鉴WHO/RHR的战略评估方案与绩效改进的理论框架,定量和定性调查相结合,对我国西南、西北、华中地区三个省份进行了调查研究。本研究分为三个部分,第一部分是在三个项目省内抽取20%的县和一个试点县的所有乡,进行计划生育服务机构资质、服务项目及术前检查的信函调查;第二部分是三个项目省内各选择一个试点县及一个试点乡的计生服务机构,进行设施设备、技术人员配备、服务过程及服务质量管理状况的现场观察,以及对服务对象、计划生育管理人员、技术服务人员的个人访谈和技术服务人员的知识水平测试;第三部分是试点乡镇各120名参加当地定期环情孕情检查的已婚育龄妇女,进行计划生育技术服务情况的定量问卷调查。【研究结果】1、定量问卷调查结果:共调查了380名已婚育龄妇女,对象平均年龄为31.89岁,文化程度以中等教育水平为主(70%),职业以农民为主(64.2%),居住地区以农村为主(81.1%)。群众对计划生育技术服务的满意比例为69.2%,在30.8%不满意的对象中,67.6%对计划生育技术本身表示不满,16.2%对服务提供表示不满,16.2%对二者均表示不满。群众对计划生育技术服务的需求中,67.1%的对象需要避孕节育咨询、自我保健咨询服务,66.3%的对象提出最需要的服务是对妇科疾病或避孕药具使用后不良反应的检查与治疗,17.1%的对象希望提供效果好副反应小的避孕方法。对满意度影响因素分析与对比的结果显示,宁夏与河南的满意度比重庆的满意度高,农民比非农民的满意度低,现用避孕与意愿避孕一致者满意度高。服务质量等级较好者比服务质量等级较差者满意度高。对满意度主要影响因素的进一步分析显示,宁夏、河南,现用宫内节育器避孕者,能够自主选择避孕方法者,其现用避孕方法与意愿避孕方法的一致比例高;宁夏,等候服务时间较短者,住所与计生服务站近者对服务过程质量评价高,了解知情选择优质服务者相对于不了解者对服务过程质量评价低;积极参加计生宣传活动者,能看懂宣教材料者对知情选择优质服务的了解比例较高。但计划生育宣传活动中,避孕节育知识方面的内容较少且较简单,宣教作用不能充分发挥。3、服务机构服务范畴及服务能力:共完成了32个县及32个乡的信函调查;3个县及3个乡计生服务机构的现场观察,41名服务对象、11名计划生育管理人员、6名技术服务人员的个人访谈,18名技术人员的知识水平测试。调查的所有计划生育服务机构都取得了计划生育技术服务机构许可;县级机构开展手术情况较全面,所有机构都能够提供放置与取出宫内节育器术、负压吸宫术,90%以上的机构开展放置与取出皮下埋植剂术、小于49天药物流产及女性绝育术,60%以上的机构开展男性绝育术;乡级机构以放置与取出宫内节育器术为主,约60%的乡级服务站能够开展负压吸宫术等其它手术。各机构能够提供的药具品种多样,且多是国家推荐目录内的品种,近30%的机构仍提供已被撤出国家目录的部分品种如药铜165宫内节育器等;各机构多数能开展手术前B超、白带检查与血常规检查,其余术前检查项目如肝肾功能、血型、出凝血时间、心电图等检查只有部分机构开展,几乎没有能完全执行国家要求必做的全部术前检查项目的机构。对项目试点县乡进行现场观察发现,县级服务机构中技术人员数量占机构人员总数的74.6%,比国家要求(80%)少约5个百分点;开展手术要求具有的相应临床执业人员只占48.7%;护理与检验人员少,有的省平均每机构不足1人。乡级机构技术人员只占机构人员总数的47.1%,远低于国家要求(3/4);具有临床执业资格者只占机构人员总数的19.3%;护理与检验人员少,有的甚至缺如。县级多数有便携式和台式B超仪,无心电图机、X线放射检查条件,无供血、配血条件;乡级一般仅有使携式B超和尿妊娠试验条件。各机构仍在使用消毒效果差的消毒剂如新洁尔灭为手术备用器械消毒。一些管理人员不清楚如何配备必要的物资。现有的例平包干经费标准已无法覆盖按国家标准开展的服务项目。经费问题是制约服务规范性开展的因素之一。各机构基本未建立有效的质量控制体系,服务记录参差不齐,对工作的考核仍以数量考核为主。国家制定的规范操作性、实用性不强,有的要求太高,实际工作中难以做到。【结论和建议】1、群众的计划生育技术相关知识少影响群众对方法的信任和使用。建议调整计划生育宣教活动的内容,提高服务提供者的咨询能力,增强群众对避孕技术的知识水平和使用能力,提高群众满意水平。2、避孕方法的有效性、安全性及使用是否方便影响群众对避孕方法的信任。建议基层服务提供中使用国家推荐的避孕药具品种,去除已被撤出国家目录的品种。3、技术人员数量和服务能力不足,专业配置不合理影响技术服务质量。建议落实护理与检验人员编制,调整针对计划生育技术的人员培养、职称晋升机制,将技术人员的进修培训制度化,全而提高技术服务能力。4、经费补偿不合理是规范的术前检查难以执行的原因之一。建议对计划生育技术服务内容及费用进行科学合理界定及经济学测算,调整例平包干经费标准。5、设备水平比较落后,诊断条件单一。建议加强计划生育服务网络和设施设备的建设,尤其是手术室和消毒供应室的建设和规范,配置和更新必需的医疗设备和器械,,确保开展优质服务的需要。5、技术服务的质量监督控制不合理,服务管理体系不能有效运作。应建立和完善各种质量控制制度与管理规程,完善服务记录、信息统计、评估考核的内容和程序,推动服务站标准化、规范化、制度化建设。7、国家对计划生育技术服务的规范要求可操作性不足。建议在全面系统评估避孕节育技术的基础上,形成基于我国数据的技术规范并定期更新,明确开展技术服务的条件,规范咨询服务流程、术前准备、技术操作过程和对规范传达实施的要求,给基层以科学实用内指导。更多还原

【Abstract】 【Background】During last three decades,China has achieved tremendous success in birth control.However,quality of family planning service had not been paid enough attention to.After the 1994 International Conference on Population and Development(ICPD),which advocated quality of service and qualified reproductive health care,China has made a decisive change to an integrated population policy to suite the social development better.Provision Quality of Care in family planning service initiated by National Population and Family Planning Commission of China requires normalized management system based on advanced science and technology.Compared with eastern China, central and western China is less developed.How to carry out family planning program with Quality of Care in central and western rural regions has become a crucial challenge in current China.【Objectives】To describe clients’ satisfaction and the actual quality of family planning service in central and western rural regions.To explore the impact factors associated with clients’ satisfaction and with quality of family planning service and find out measures that could bridge the gap between current performance and good quality of care.【Methods】This is a cross-sectional study.The Strategic Approach framework developed by WHO/RHR and the Performance Improvement framework developed by Human Performance Technology were used.Quantitative and qualitative methods were adopted in the fieldwork.Each of the study sites includes one county and one township in Chongqing Municipality,Ningxia Hui Nationality Autonomous Region and Henan province.Twenty percent counties of each province and townships of a whole county were randomly selected and their family planning courses at county level or township level were investigated by mail questionnaire.At one county and one township in each of the study provinces,the service facilities,procedures and quality control systems were observed on the spot.Family planning administrative staff,service providers and some clients exited from service were interviewed by research staff.Some married women at reproductive age at study sites were investigated with a structured questionnaire.【Results】1.Clients’ satisfaction and influence factors:Three hundred and eighty married women were interviewed with structured questionnaire.The mean age was 31.89.About 70%of them were graduated from middle school,81.1%lived in rural area and 64.2%were farmers.The observed proportion of women satisfied with family planning service was 69.2%Among the 30.8%of dissatisfaction,67.5%were dissatisfied with contraceptive method,16.2%were dissatisfied with the provision of service and 16.2%were dissatisfied with both of them.About 67%of the women wanted consulting service of family planning and self-health care,66%of them demanded treatment of Gyn-diseases and side effects of contraceptive methods,and 17%of them demanded contraceptive methods with high effectiveness and low side effects.Higher clients’ satisfaction was associated with province of Ningxia or in Henan, nonagricultural occupation,accordance between contraceptive using and the women’s own will,and higher quality of care.Moreover,higher accordance was associated with Ningxia or Henan,IUD user,independent contraceptive selection.Ningxia,shorter waiting time,and shorter distance between clients’ habitation and the clinics were associated with higher evaluation of quality. Family planning propaganda contributed to client’s acquaintance with quality of care,but the content of the propaganda with poor contraceptive knowledge could not worked as expected.2.Quality of care and associated determinants:A total of 32 county family planning clinics and 32 township family planning clinics were investigated by mail questionnaire.Three family planning clinics at county and three at township level were observed on the spot.Forty-one clients,eleven administrators and six service providers were interviewed by the research team.Eighteen service providers took the exams to test their relevant medical knowledge. It was showed that networks for family planning service were basically set up in the study sites and all study clinics were licensed by family planning administration.Inserting or removal IUDs or implant,surgery abortion and medical abortion were in the service categories at over 90%county level study sites.Inserting and removal IUDs were the main kinds of service items at township level sites.Most of the clinics provided the contraceptive methods within the national category,but 30%still provided those removed from the national category,such as medical copper ring 165,etc.It was commonly observed that laboratory examinations were insufficient in most clinics except type-B ultrasonic examination,vaginal discharging test and blood routine examination.None of the clinics could provide the whole set of obligatory examinations.The number of skilled service providers was insufficient in the study sites. Percentage of service providers in the clinics at county level was 74.6%and town level was 48.7%,which was less than the national requirements.Lack of certificated clinic providers,especially nurses or laboratory technicians was commonly existed.Type B-ultrasound machine was generally equipped;some other such as electrocardiogram or X-ray machine was not equipped in most of the study sites.Benzalkonium bromide,a kind of proved bad efficacy sterilant,was still in use at the study sites.Some administrators did not know what element supplies should be prepared for quality of care.It was one thing that lack of service capacity influenced the actual performance, shortage of funds were quite another.The compensation for free family planning service was less than the real cost.The monitoring of service quality was inappropriate and the management system was not effectively operated. On the other hand,the national guidelines were not practical enough to guide the practice well.【Conclusions and Suggestions】1.The contraceptive and reproductive health knowledge is rather limited in family planning propaganda.Such knowledge should be increased.It should be helpful to conduct a variety of forms of propaganda,so as to enhance clients’ contraceptive knowledge and capability of using contraceptive methods, and further,to increase their satisfaction on family planning service.2.The effectiveness,safety and convenience are the most important concerns of contraceptive adoption.We suggest that the method mix in rural family planning clinics should include those from the state’s contraceptive method category,which recommended by National Population and Family Planning Commission.3.The lack of service providers and their poor capability of service provision impacted the quality of care.Further training of service providers and a well-designed promotion mechanism are needed in family planning sector.4.The compensation for free family planning service could not cover the real cost.This is one of the main causes that the lab test was not routinely conducted in study sites.It is needed to review what should be provided in family planning service and how much it costs.Increasing financial support to cover the real cost of free family planning service is the key element to improve quality of family planning care.5.The infrastructure is obsolete and the diagnosis equipment is not enough. It affected the quality of care as well.Improvement of infrastructure and provision of diagnosis equipment to meet the basic requirement are needed in rural area of the study sites.6.The monitoring of service quality is inappropriate and the management system is not effectively operated in study site.It is needed to establish and improve the monitoring as well as management.7.The performance guideline for family planning service is not very practical. An updating guideline is needed,which gives detailed information on service environmental requirement,procedure,operation procedure,etc.更多还原