【摘要】 目的 (1)研究新疆肺结核病患者、可疑症状者和社区居民对肺结核病的认知、态度和行为,为推动健康促进融入结核病控制项目提供依据;(2)研究在贫困、边远及民族地区早期发现、及时治疗肺结核病人时存在的障碍因素,提高项目地区肺结核病早期发现率和DOTS策略的执行;(3)通过试点研究探索在项目地区推广社会评价的必要性与可行性。方法 2004年在新疆定性研究和定量研究相结合,定量研究对吐鲁番市、察布查尔县和疏附县3个市、县中221名肺结核病患者、223名可疑症状者和631名社区居民进行入户询问调查;定性研究通过县医院医生、乡卫生院医生和社区居民20个专题小组讨论和98名医务人员、肺结核病人、可疑症状者以及政府和相关部门领导进行个别访谈后收集整理大量信息后进行分析。结果 (1)被调查者对肺结核病的认知程度存在“三低一高”的现象:①对结核病具有传染性和能够治愈的认知程度低,60%以上调查对象不知道肺结核病有传染性,10%以上居民认为肺结核病不能治愈,对肺结核病的认知程度低是早期发现病人和及时治疗病人的主要障碍;②对结防机构和提供结核病免费诊治的知晓率低,1/5的居民不知道有结防机构,1/3的可疑症状者不知道有结核病免费诊治项目;③现代传播媒体传播肺结核病知识的作用低,传播结核病知识的渠道主要以“医生的介绍”和“聊天”为主;④调查对象中担心社会歧视的程度高,43.6%的居民对肺结核病患者有歧视现象和恐惧感。(2)医疗费用:①肺结核病患者医疗花费平均2 363元/人,占全家总支出(2003年)的1/5,是病人家庭的沉重经济负担;②诊断前医疗费用超过诊断后医疗费用;③就诊次数增加,病人的平均医疗费用增加。(3)就诊、确诊及治疗延迟:①就诊延迟相当严重,39.4%的TB病人从出现症状至首次就诊超过3周,甚至有18.6%的病人超过6周,可疑症状者超过3周者占32.3%,超过6周者6.7%;②从首次就诊至确诊超过2周者占49.5%,其中超过4周者占44.5%;③85.3%的病人从确诊至开始治疗不超过1周。说明病人一经确诊,基本能及时得到规范的治疗,治疗延迟程度比较轻。(4)影响因素分析:①男性就医优先权高于女性,老年男性就医优先权明显;②对结核病的认知程度男性优于女性,年轻者对结核病的歧视与担忧较年长者严重;③女性就诊延迟较严重,随年龄的增长诊断延迟率越严重;④经济状况越差诊断延迟率越高;⑤文化程度低的TB病人和居民对肺结核病以及结防机构的认知率低于文化程度高者。(5)民族特征:①新疆维吾尔自治区是肺结核病高发区,疫情严重,本次调查人群中维吾尔族和哈萨克族居民患病率高、认知率低、就诊延迟程度严重;②本次调查人群中维吾尔族肺结核病患者医疗费用高于其他民族,疾病负担严重。(6)就医途径:①调查对象中首次就诊机构选择乡镇卫生院者约占一半,这一点与其他调查省明显不同,其他调查省约有40%~50%的调查对象首选卫生机构是村卫生室;②平均每名肺结核病患者确诊前就诊4.2次,可疑症状者就诊3.2次;③2/3以上可疑症状者未转诊,其中2/3由于自己的原因未转诊,只有1/3是医务人员没有建议病人转诊。(7)执行DOTS策略:①57.7%的病人认为没有必要在直接面视下服药,73.3%的病人是有人看着服药的;②85.3%的病人在服药过程中有县、乡、村三级医务人员上门防视;③治疗过程中漏服药占11.6%,其中半数是因为有药物反应才导致了漏服;④有6.5%的病人中断服药,其中2/3的病人中断服药发生在治疗后2个月。(8)决策者与相关部门领导反映主要问题有3方面:①尽管已经有政策,但仍无法落实县级按人均0.1元的肺结核病防治专项经费;②医疗机构出于经济方面的考虑,不能严格执行归口管理政策,存在截留病人现象;③对于贫困县,卫生部门业务经费原本紧张,由于落实垫支经费有一定难度,当前结核病项目采用的先垫支后报帐的制度,给开展工作造成了一定阻力。结论 (1)提高知晓率:①加强健康教育力度,普及结核病知识,将健康教育促进融入结核病控制项目,提高群众对结核病的认知率;②充分发挥现代传播媒体的作用普及结防知识,尤其在高发病地区利用电视、广播、报刊和书籍等媒体,除利用“3.24世界结核病日”突击宣传外,还应开展经常性的宣传活动,使广大群众认识结核病,正确对待结核病;③在群众中消除对结核病的恐惧意识,关爱病人,消除对结核病人的歧视(尤其是年轻患者)。(2)降低费用:①加强宣传教育,使患者出现症状后及时去结防机构早期诊断,减少诊疗次数,降低医疗费用;②提高对专业结防机构和免费诊治项目的知晓率,使病人及时得到免费治疗,治疗过程中尽量减少辅助用药,减轻病人经济负担。(3)及时就诊:①加强健康促进,使人们一旦出现可疑症状能及时就诊;②完善县、乡、村三级医疗网的建设,提高医务人员对TB的识别能力,有条件的乡卫生院可以增设痰检项目;③提高归口管理的能力,及时将可疑症状者转至县专业防治机构确保病人早发现、早治疗。(4)关于影响因素:①进一步确认低收入、低文化是人们就医的主要障碍因素;②贫困者、文盲、女性、高龄人群是肺结核病患者中的弱势人群,应在政策上为弱势人群的诊治提供优惠条件;③关注并采取措施解除年轻女性对肺结核病的耻辱感和担忧。(5)关于就医:①加强村卫生室的建设,提高第一级医疗机构的业务能力,改变群众就医流量倒置现象;②实现早期发现肺结核病患者的目标,三级医疗机构应警惕早期症状的患者和可疑症状者,降低患者诊断前的就诊次数;③加强宣传力度,提高结防机构知名度,使出现早期症状者去结防机构尽早诊断,及时治疗。(6)执行DOTS策略:①DOTS策略执行过程中成绩显著,多数病人已无需直接面视督导;②充分发挥村医的作用,继续减少治疗过程中漏服药和中断服药的比例;③进一步分析村医在治疗过程中的直接面视程度。(7)加强组织管理:①开展健康促进,在人群中普及结核病知识(真正能到农村居民手中的材料有限,信息更有限),利用农村居民可以接触到的方式、能理解的语言进行结核病防治宣传,有利于农村居民的健康促进工作,医务人员应在结核病防治、健康促进中发挥更大作用,利用患者就诊的机会开展面对面的信息传播与交流,乡卫生院医生是关键(乡卫生院往往是患者首诊医院,而且门诊量不多,医务人员有时间进行健康教育);②将痰涂阴性的肺结核病患者纳入免费治疗,将有利于结核病防治工作的开展,有利于由于经济困难而延迟就诊或不能完成治疗的农村肺结核病人减轻经济负担,有利于树立专业结防机构和卫生部门的良好信誉;③协调医疗机构和结防机构的关系,实现肺结核病人管理的良性运行充分发挥医疗机构和结防机构在结核病防治中的积极作用,协调二者的关系与利益,使其共同为提高肺结核病的发现率和治愈率贡献力量;④适当提高乡村医务人员待遇,落实DOTS方案,落实DOTS方案的关键是乡村医务人员,但当前乡村医务人员待遇低,边缘、少数民族地区地域辽阔,交通不便,给DOTS方案的实施带来不便。适当提高乡村医务人员待遇,可以鼓励其有效开展工作,更好地实施DOTS方案⑤加强对药品市场的管理加强对药品市场的管理力度,严格执行处方药管理制度,严格抗结核药物的管理,避免或减少由于不规范用药而造成的结核病耐药现象。更多还原

【Abstract】 Objective(1) To study the situation of the cognition, attitude and behavior of patients with tuberculosis(Tb), people with suspicious symptoms and inhabitants from different communities in Xinjiang.(2) To research the obstacle factors in early discovery, timely therapy of patients with Tb in the poverty, remote and minority areas.(3) To seek the necessity and feasibility of extending social assessment in the project areas. Methods Qualitative and quantitative investigation were carried out in Xinjiang in 2004. Quantitative investigation was made in 221 patients with Tb, 223 persons with suspicious symptoms and 631 inhabitants from communities of 3 cities/counties of Turpan City, Qapqal County and Shufu County by entering their houses for inquiry. Qualitative investigation was implemented by discussion in 20 special groups among inhabitants of communities, doctors from health centers of countryside and hospitals of counties, acquisition of information through individual interview with Tb patients, people with suspicious symptoms, 98 medical staffs and directors of relative departments. Results(1) There were 60% of informants to be ignorant of the infectivity of Tb and 10% of the informants to be under the impression of its unable cure. That is the major obstacle to discover patients early and treat patients in time. Twenty percent inhabitants was unaware of the existent of institutions of Tb control, one-third people with suspicious symptoms knew nothing of the free diagnosis and treatment of Tb. The knowledge propaganda of pulmonary Tb by modern transmission media was ineffective. The way of getting knowledge by inhabitants was mainly through chat and doctors’ introduction. The inhabitants were highly afraid of social discrimination, and 43.6% of the inhabitant had discrimination and fear of the patient with Tb.(2) Hospitalization costs: The therapy cost of patients with Tb was 2 363 Yuan RMB por person on an average,accounted for 20% of the total cost of a family. The hospitalization cost was more before diagnosis than after diagnosis. The increase of visiting times resulted in the rise of hospitalization cost of patients.(3) The patient delayed visiting doctors, being confirmed diagnosis and treated.(4) Affecting factors: The male enjoyed priority in taking medical treatment than the female, and it was obvious in the senility male. The retarding rate of diagnosis was high in the patients in poor economic position.(5) High morbidity rate and low cognition rate were in Uygur and Kazak inhabitants with seriously delayed visiting. The hospitalization cost of the patient was high.(6) Visiting way: It accounted for 50% to select health centers of countryside for the first visiting. The patient with pulmonary Tb would be confirmed after 4.2 times of visiting(people with suspicious symptoms about 3.2 times of visiting). More than two-third people with suspicious symptoms had not been transferred for diagnosis.(7) DOTS strategy implementation: ①There were 57.7% patients who believed that there was no necessity to take medicine under facing supervisal directly, and 73.3% patients taking medicine under facing supervisal directly.② There were 85. 3% patients to be visited by medical staffs during their taking medicine.③ People missed taking medicine accounted for 11.6% in the therapy. Out of them, half missed taking due to drug reaction. ④There were 6.5% of patients aborted taking medicine.(8)Control fund: ① The fund special for pulmonary Tb control failed to be carried out in 0.1 Yuan RMB per person on an average. ② Patients were held back in some medical institutions because of economic benefit.③There was difficulty in the implementation of fund payment by health departments in the poverty counties. The system of payment prior to rendering an account caused pressure upon the work. Conclusions(1) Improving understanding rate :① To enforce health education and promote health, to improve Tb understanding rate of people. ② To give play to the modem transmission media, to propagandize effectively by media such as TV,broadcasting, newspapers and periodicals, as well as books and so on.(2) Reducing costs: ① To visiting Tb control institutions in time for the early diagnosis after symptoms appeared in order to decrease times of diagnosis and therapy. ② To improve understanding rate of professional institutions of Tb control and free items of diagnosis and therapy, to let patients get free treatment in time for decrease of adjuvant.(3) People in the poverty, illiteracy, female and senility are the disadvantage groups of the patients with pulmonary Tb. The policy should provide the favorable condition of diagnosis and therapy for the disadvantage groups. The young, especially the young female, feels more shame at and fear of pulmonary Tb than the other people. It should be paid more attention to.(4) About taking medical treatment: ① To enforce the construction of the rural clinics, to improve the professional ability of medical institutions at the first level, to change the flow inversion of people taking medical treatment. ② To achieve the aim of discovering patients with pulmonary Tb at early stage. The medical institution at the third level should be on guard against the patient with early symptoms and suspicious symptoms in order to reduce patients’ visiting times before diagnosis.③ To strengthen the propaganda for the aim of popularity improvement of Tb control institutions. To make people with early symptoms visit Tb control institutions for early diagnosis and timely treatment.(5) DOTS strategy implementation: To give full play to rural doctors so that to reduce the proportion of missing and aborting drug taking.(6) To enforce organizational management: ① Developing health promotion;② Making negative-smear patients with pulmonary Tb be treated freely; ③ To coordinate the relationship between the medical institution and the Tb control institution,to carry out the management of patients with pulmonary in good execution and give full play to medical and Tb control institutions in Tb control; ④To improve the treatment of medical staffs at countryside, to implement DOTS strategy more effectively;⑤ To strengthen the management and the administrative force of medicine markets, to execute the managerial system of prescription drugs.更多还原