本文選題：社區(qū)醫(yī)務人員 + 肥胖　； 參考：《第二軍醫(yī)大學》2017年碩士論文

【摘要】：【研究目的】超重和肥胖已成為我國一項嚴重的公共衛(wèi)生問題。社區(qū)醫(yī)務人員是實施體重管理的主體,他們干預超重和肥胖的力度關乎防治工作的成效。國內(nèi)外研究對社區(qū)醫(yī)務人員群體的關注甚少,尚不清楚當前社區(qū)醫(yī)務人員實施體重干預“執(zhí)行力度弱、行為水平低”的原因。本研究擬在課題組前期研究工作的基礎上,依據(jù)已有的社區(qū)醫(yī)務人員干預成人超重和肥胖行為(簡稱干預行為)的概念框架,建立結構方程模型,明確當前影響社區(qū)醫(yī)務人員干預成人超重和肥胖行為的關鍵因素及其作用路徑,并初步制定促進社區(qū)醫(yī)務人員實施體重管理的干預方案。本研究成果有助于理解社區(qū)醫(yī)務人員從事成人體重管理的行為機制,為今后開展干預研究提供借鑒�！狙芯績�(nèi)容與方法】本研究分為三個步驟:1、采用Delphi專家函詢法和預試驗,對課題組前期依據(jù)干預行為的概念框架形成的問卷進行檢驗和修改,以形成一套有效、可靠的調查問卷。2、采用橫斷面研究,以社區(qū)衛(wèi)生服務中心為單位,按區(qū)域分層抽樣,實施問卷調查,了解當前社區(qū)醫(yī)務人員干預成人超重和肥胖的現(xiàn)狀,分析影響醫(yī)務人員實施體重管理行為的相關變量,并參照干預行為的概念框架(變量之間的關系結構),構建相應的結構方程模型,進而檢驗理論假設,明確干預行為的關鍵變量。3、圍繞關鍵變量,采用文獻分析法,擬定推進社區(qū)醫(yī)務人員實施體重管理的措施,形成干預方案初稿;采用專家小組會議修訂方案,形成最終建議案�！狙芯拷Y果】1、問卷信效度檢驗結果(1)內(nèi)容效度:通過對13名專家的函詢結果,各條目內(nèi)容效度I-CVI為0.75~0.90,問卷總內(nèi)容效度S-CVI為0.90。(2)項目分析:各條目的CR值均達到顯著性水平。(3)結構效度:各量表因子累計方差貢獻率均70%。(4)內(nèi)部一致性信度:各分量表的Cronbachα系數(shù)為0.863~0.950;(5)重測信度(間隔2周):各分量表的組內(nèi)相關系數(shù)為0.307~0.649。正式問卷信、效度良好,包含4個分量表:(1)從事體重管理的行為(8個條目);(2)從事體重管理的知識與技能(9個條目);(3)從事體重管理的感知障礙(8個條目);(4)從事體重管理的態(tài)度信念(25個條目)。2、橫斷面調查結果(n=904)(1)描述性統(tǒng)計結果:(1)社區(qū)醫(yī)務人員實施體重管理行為水平不高,各條目人均得分為1.59~2.18,醫(yī)務人員最常實施的干預行為是“為患者提供體重相關一般性建議”(2.18±1.05),最少實施的干預行為是“測算腰圍”(1.59±0.86);(2)社區(qū)醫(yī)務人員實施體重管理的知識技能掌握程度不佳,各條目人均得分為1.80~2.37,其中掌握最好的是“超重及肥胖可能帶來的危害”(2.37±0.63),掌握最差的是“為患者情況制定合理的減重目標及個性化的減重計劃”(1.85±0.62);(3)從事體重管理的感知障礙水平較高,各條目的人均得分為4.07~4.82,其中醫(yī)務人員最認同的障礙為“開展體重干預工作的資金不足”(4.82±1.81)。(2)通過t檢驗、單因素方差分析、Pearson相關分析篩選變量,析出社區(qū)醫(yī)務人員實施體重管理行為的影響因素,包括:(1)人口統(tǒng)計學因素,如性別、學歷、是否出現(xiàn)過體重問題等;(2)職業(yè)因素,如專業(yè)、職稱、知識技能、相關培訓經(jīng)歷;(3)態(tài)度信念因素,如職業(yè)角色認同、環(huán)境和資源(障礙感知)、自我效能、結果信念、意向、社會壓力、社會支持、權力、習慣/過去行為。(3)路徑分析結果:知識和技能可通過影響全科醫(yī)生/社區(qū)護士行為信念影響體重管理行為(間接效應為0.2%/0.4%),也可直接作用于個體行為(直接效應為43.3%/47.6%);社會影響通過影響個體認知或行為意向,間接影響個體行為(總效應為2.1%/9.9%);個體認知,如自我效能(總效應1.4%/2.3%)、職業(yè)角色認同(總效應0.3%/9.1%)等通過影響行為意向及習慣/過去行為影響行為�；谏鲜鲅芯拷Y論形成社區(qū)醫(yī)務人員干預成人超重和肥胖的行為機制模型,最終形成的模型R2為26.3%(全科醫(yī)生)/25.4%(社區(qū)護士),即納入模型的因素可解釋行為水平26.3%/25.4%的變異。模型χ2/df3、GFI、AGFI、NFI、IFI、CFI均大于0.9,RMSEA0.08,各指標提示模型的擬合情況仍較好,各擬合指標均達到了要求。3、形成“促進社區(qū)醫(yī)務人員干預成人超重或肥胖行為的措施”實施方案(1)促進社區(qū)醫(yī)務人員干預成人超重和肥胖的主要措施:(1)加強培訓,提高社區(qū)醫(yī)護人員體重管理的知識技能和自我效能感;(2)明確職責,加強督導,提高社區(qū)醫(yī)護人員的干預意愿;(3)提供材料和資源,便于社區(qū)醫(yī)護人員實施體重管理干預;(4)多科室合作,提高體重管理專業(yè)性與科學性。(2)效果評價指標及評價時間:(1)醫(yī)護人員評價指標,如醫(yī)護人員體重管理行為、醫(yī)護人員知識技能、醫(yī)護人員實施體重管理的信念等;(2)患者評價指標,如患者體重、腰圍、BMI及患者健康行為;(3)評價時間:實施干預后3個月、6個月、1年等�！狙芯拷Y論】1、社區(qū)醫(yī)務人員實施成人體重管理的行為水平低,受多種因素影響。其中,知識技能水平和感知的社會支持作為關鍵因素,可直接影響干預行為水平的高低。2、基于TPB(Theory of planned behavior,計劃行為理論)和SCT(Social cognitive theory,社會認知理論)嵌套形式的概念框架,從個體、人際間和社會三個層面揭示了干預行為發(fā)生的機制,有助于理解社區(qū)醫(yī)務人員干預體重水平低的原因。3、提高社區(qū)醫(yī)務人員實施體重管理的知識和技能,調動醫(yī)務人員積極性,是促進社區(qū)醫(yī)務人員干預成人超重和肥胖的重要舉措。
[Abstract]:[Objective] overweight and obesity have become a serious public health problem in China. Community medical staff are the main body of body weight management. Their intervention in overweight and obesity is related to the effectiveness of prevention and treatment. Research on the community medical staff at home and abroad is very little, and it is not clear that the current community medical personnel are implemented. On the basis of the previous research work of the group, this study aims to establish a structural equation model based on the conceptual framework of the existing community medical personnel intervened in adult overweight and obesity behavior (intervention behavior), and it is clear that the community medical workers interfere with the overweight and fertilizer of adults. The key factors and the path of action of fat behavior, and the preliminary formulation of intervention programs to promote the implementation of body weight management for community medical workers. The results of this study are helpful to understand the behavior mechanism of community medical staff in adult weight management and provide reference for future intervention research. [research content and methods] this study is divided into three steps: 1, the Delphi expert inquiry method and pre test were used to test and modify the questionnaire formed by the conceptual framework of the intervention behavior in the earlier period, so as to form a set of effective and reliable questionnaire.2, using a cross-sectional study, taking the community health service center as a unit, stratified sampling according to the regional area, and carrying out a questionnaire survey to understand the current community medicine. The staff intervened the status of overweight and obesity in adults, analyzed the relevant variables affecting the behavior of body weight management by medical staff, and constructed the corresponding structural equation model referring to the conceptual framework of intervention behavior (the relationship structure between variables), and then tested the theoretical hypothesis, and made clear the key variable of intervention.3, and adopted the text around the key variables. Analysis method, formulate measures to promote community medical staff to implement weight management, form the first draft of intervention program; adopt the expert group meeting to revise the plan to form the final proposal. [results] 1, the result of the questionnaire and validity test (1) content validity: through the consultation results to 13 experts, the content validity of each item is I-CVI 0.75~0.90, questionnaire The total content validity S-CVI was 0.90. (2) project analysis: the CR values of all items reached significant level. (3) structural validity: the cumulative variance contribution rate of each scale factor was 70%. (4) internal consistency reliability: the Cronbach alpha coefficient of each subscale was 0.863~0.950; (5) retest reliability (interval 2 weeks): the intra group correlation coefficient of each subscale was 0.307~0.649. formal The validity of the questionnaire included 4 subscales: (1) the behavior of body weight management (8 items); (2) knowledge and skills (9 entries) engaged in weight management (9); (3) the perception barrier (8 items) engaged in weight management (8); (4).2, n=904, 1): (1) descriptive statistical results: (1) society The level of body weight management in district medical workers was not high, the average score of each item was 1.59~2.18. The most common intervention of medical staff was "general suggestion of providing weight for the patients" (2.18 + 1.05). The least implementation intervention was "measuring the waist circumference" (1.59 + 0.86); (2) the knowledge of body weight management in community medical staff. The skill mastery was poor, and the average score of each item was 1.80~2.37. The best mastery was "the risk of overweight and obesity" (2.37 + 0.63). The worst mastery was "a reasonable weight reduction target and a personalized weight reduction plan for patients" (1.85 + 0.62); (3) the level of perception barriers in body weight management was higher, The average per capita score was 4.07~4.82, and the most recognized barriers for medical staff were "insufficient funds to carry out weight intervention" (4.82 + 1.81). (2) through t test, single factor analysis of variance, and Pearson correlation analysis, the factors affecting the implementation of body weight management in community medical staff were analyzed, including: (1) demographic factors, such as Gender, educational background, weight problems, etc. (2) occupational factors, such as professional, professional, knowledge and skills, related training experience; (3) attitude and belief factors, such as professional role identity, environment and resources (barrier perception), self-efficacy, belief, intention, social pressure, social support, power, habit / past behavior. (3) path analysis results: Knowledge: knowledge And skills can affect body weight management behavior by affecting the behavior beliefs of general practitioners / community nurses (the indirect effect is 0.2%/0.4%), and can also directly affect individual behavior (direct effect is 43.3%/47.6%); social influence indirectly affects individual behavior (the total effect is 2.1%/9.9%) by influencing individual cognition or behavioral intention; individual cognition, such as self effect, is influenced by the social influence. Ability (total effect 1.4%/2.3%), professional role identity (total effect 0.3%/9.1%) and other behaviors affecting behavior intention and habit / past behavior. Based on the above conclusions, a model of behavior mechanism for community medical staff to interfere with overweight and obesity is formed, and the final model R2 is 26.3% (general practitioner) /25.4% (community nurse), namely the model of inclusion model. The factor of type can explain the variation of behavior level 26.3%/25.4%. Model chi square 2/df3, GFI, AGFI, NFI, IFI, CFI are all greater than 0.9, RMSEA0.08, the fitting of each index model is still better, each fitting index has reached the demand.3, forming "measures to promote community medical staff to intervene the behavior of overweight or obesity" (1) promote the community The main measures for medical staff to interfere with overweight and obesity: (1) strengthen training, improve the knowledge skills and self-efficacy of the body weight management of the community medical staff; (2) clear responsibilities, strengthen supervision, improve the intervention will of the community medical staff; (3) provide materials and resources to facilitate community health care workers to implement weight management intervention; (4) multidisciplinary integration To improve the professional and scientific nature of weight management. (2) the evaluation index and time of effect evaluation: (1) the evaluation indexes of medical and nursing staff, such as the behavior of body weight management, the knowledge and skill of medical staff, the belief of the medical and nursing staff to carry out the weight management; (2) the evaluation of patients' weight, waist circumference, BMI and patient's health behavior; (3) evaluation time: 3 months, 6 months, 1 years after the implementation of the intervention. [Conclusion] 1, the behavior level of the community medical staff in the implementation of adult weight management is low and affected by many factors. Among them, the level of knowledge skills and perceived social support can directly affect the level of intervention behavior, based on TPB (Theory of planned behavior, plan). Behavior theory) and the conceptual framework of nested form of SCT (Social cognitive theory, social cognition theory), which reveal the mechanism of intervention from three levels of individual, interpersonal and social, and help to understand the cause of community medical staff to interfere with the low level of weight,.3, the knowledge and skills of carrying out weight management in community medical staff. The initiative of medical staff is an important measure to promote community medical personnel to intervene in overweight and obesity in adults.
【學位授予單位】：第二軍醫(yī)大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R473.2

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