公共卫生服务评价概念框架及指标体系的研究
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摘要
研究背景:社会经济的迅速发展和人们保健意识的不断增强,使人们更关心公共卫生问题。政府、社区、社会大众希望更多地了解公共卫生服务,以及公共卫生服务的质量。全面准确地评价公共卫生服务的质量需要多个指标有机组合起来的指标体系。指标体系不是指标的简单堆积,指标体系应能测量公共卫生系统的不同的维度,并能提供这些维度如何有机的组合在一起来产生总体的效果。指标体系提供的信息应远多于指标体系组成部分提供信息的总和。多年公共卫生服务的研究和实践,出现了许多灵敏反映公共卫生服务质量的指标和指标体系,但大部分指标体系按公共卫生服务的部门和工作内容构建,缺乏系统性、理论性的概念框架。制定公共卫生服务评价概念框架将有助于构建结构合理、分布均衡的公共卫生服务评价的指标体系,可提供一个公共卫生服务评价指标的科学分类方法,并使指标的解释更加容易。概念框架还将有利于产生系统、综合的信息,并产生科学的公共卫生政策。研究发现,由于公共卫生指标缺乏标准化,致使相同的指标往往有许多不同的定义,造成了数据的交换整合、指标的理解困难,也不利于公共卫生政策的科学制定。因此,公共卫生指标元数据的研究日益受到广泛的重视。
目的:探索公共卫生服务评价概念框架建立的理论和方法,构建公共卫生服务评价概念框架,确定框架的结构(维度、子维度)及其构成部分的关联关系;根据概念框架建立公共卫生服务评价的指标体系;确定公共卫生服务指标元数据的描述方法。
方法:在卫生服务质量评价模型和健康影响因素模型的基础上,通过文献分析法建立概念框架的初始模型,经专家会议论证、修订,确定概念框架的结构、维度和子维度。以问卷调查的方式,请公共卫生信息会议参加者和公共卫生领域的专家进行概念框架的评价。根据概念框架的研究成果,依据概念框架的维度和子维度构成和指标的选择标准,确定公共卫生服务评价指标体系的初始问卷,通过Delphi专家问卷咨询法,确定指标体系。利用国家第三次卫生服务调查分析报告的数据,依据概念框架对数据再分析。并通过卫生服务数据,了解卫生服务指标间的相互关系。
结果:提出了健康结果、健康的非医学因素、公共卫生服务提供、支撑体系四个维度和十五个子维度组成的概念框架,确定了维度的定义和内涵,维度间和维度内子维度间的相互关系。健康结果维度包括完满健康、健康状态、人体功能和死亡四个子维度;非医学健康因素的4个子维度是健康行为、社会经济因素、生物遗传因素和环境因素;公共卫生服务提供维度包括疾病预防控制、卫生监督检测、健康教育和妇幼保健四个横向维度,和有效性、及时性、安全性、可接受性、连续性、反应性、可及性、适宜性和效率的纵向维度;支撑体系维度包括机制保障、资源保障和政策法规保障。健康结果反映公共卫生服务的结果,健康的非医学因素反映公共卫生服务的中间结果,公共卫生服务反映公共卫生服务的过程,而支撑体系反映公共卫生系统的结构特征。公共卫生服务的公平性反映在公共卫生服务的全过程,框架中将其作为和其他四个维度的交叉维度,而不作为一个单独的维度。概念框架得到了公共卫生信息与会者和公共卫生领域专家的认可。
共遴选了26位国内知名的公共卫生学者和专家参加了两轮指标体系Delphi法专家问卷咨询调查,第一、二轮咨询调查的专家积极系数分别为0.71和0.94。根据专家咨询调查的分析结果确定了由62个指标构成的指标体系,指标体系的协调系数表明专家咨询有较好的一致性。
利用国家卫生服务调查的聚合数据,分析了从分析报告中抽取的31个指标间的相互关系。结果表明:健康结果、健康的非医学因素、公共卫生服务和支撑体系指标间存在着复杂的相关关系。影响因素线性多元回归的分析结果表明,社会经济因素对健康结果、健康行为和卫生服务的利用有重要的影响。通过比较不同类别地区卫生服务评价指标发现,如城市和农村间,不同收入水平和教育程度的地区间卫生服务指标间存在显著的差异。
指标是从数据元产生的新的、特殊的数据元。建立在数据元元数据研究的基础上,结合公共卫生指标的特点,本研究建立了指标元数据的描述方法。这将有助于指标的标准化。
结论:建立在卫生服务质量评价和健康影响因素模型基础上,经大量文献分析和专家咨询,在国内第一次提出了公共卫生服务概念框架,并对概念框架的维度和子维度进行了详细的描述。框架得到了公共卫生信息工作者和公共卫生领域专家学者的一致认可。对于构建指标体系、指导数据分析有非常重要的意义。公共卫生指标元数据的描述方法将有利于指标的标准化。
Background: The rapid social and economical development and increasing sense of health protection have made people care more about their health problem and public health. The government, community, and society know about public health service and the quality of public health services, and it requires an indicator system comprised of inherently connected indicators to evaluate the quality of public health correctly and comprehensively. The indicator system is more than just a collection of indicators. It should be able to measure its distinct components of the system and also provides information about how the individual components work together to produce the overall effect. In other words, the whole of the information provided by a system of indicators is greater than the sum of its parts. After many years of public health research and practice, we have compiled a set of indicators and developed an indicator system to reflect public health service. However, most of indicator systems in the public health field were built based upon the tasks and components of public health department. These indicator systems do not have solid conceptual framework.
The development of the conceptual framework for public health service will help to build indicator system which is well-structured and evenly distributed. At the same time the conceptual framework will provide a scientific classification method for indicator and make it easy to explain the indicator. The conceptual framework can help to generate systematic and comprehensive information, which can be used to formulate public health policy. It is found that the same indicator sometimes has many different definitions. The lack of standardization for indicator make it difficult for data exchange and data integration and also affect the development of public health policy, therefore, the study of indicator metadata have been emphasized much.
Objectives: To explore the theory and method of developing conceptual framework for public health service, to establish the conceptual framework of public health service and to define the structure and components of the framework and the relationships among them. To build indicator system of public health service based upon the framework. To establish the methods of defining the metadata of indicator and indicator system.
Methods: The initial conceptual framework was constructed on the basis of the results of literatures review and concept analyses. The development of conceptual framework is based upon health determinant model and the theory of healthcare quality evaluation. The initial framework has been modified based upon the suggestions given by experts during the expert meeting to validate the framework. Some domains and sub domains were removed and some domain and sub domains are redefined. The modified framework was evaluated by public health information conference attendee and experts and scholars in public health area via a questionnaire survey.
The initial indicator questionnaire was drafted according to the newly created conceptual framework and the selecting criteria of indicators are followed. The two-round Delphi survey was conducted to establish the indicator system for public health service. The data from analysis report of national health services survey in 2003 was analyzed according to the framework. The abstracted 31 indicators were utilized to understand the complicated relationships between and within domains (or sub domains)
Results: A conceptual framework consisting of four domains and 15 sub-domains is developed. The 4 domains are health status, non-medical health determinants, provision of public health service, and the supporting system. The health outcome includes three sub-domains of wellbeing, health status, functional status, and death; Non-medicine health determinants domain consists of health behavior, biological and genetic factors, social and economic factors and physical environmental factors; public health domain includes two dimensions. Vertical domain is made up of effectiveness, timeliness, safety, accessibility, continuity, responsibility, appropriateness, and efficiency; and horizontal domains includes disease prevention and control, health education, Children and maternity care and health protection. The supporting system has three sub-domains. They are resource assurance, mechanism assurance and regulation and policy assurance. The complicated relationship between these domains is also described. The notion of equity spans all dimensions of the framework, and can apply equally to any construct or dimension. Therefore equity is not included as a fifth dimension of the Health Indicators Conceptual framework, but is presented as a crosscutting element of the framework that applies to each of the four dimensions.
The structure and components of the conceptual framework were highly recognized by public health information conference attendee and experts in public health fields. Twenty-Four (26) experts and scholars working in public health area were selected to participate in two-round Delphi questionnaire survey. The active coefficients of first and second round are 0.71 and 0.94, respectively. The final indicator system has 62 indicators. The results of Kendall's W test shows the higher concordance in both rounds of consultation.
The comparisons of health indicators abstracted from health service report support that there are tremendous differences between the urban population and rural population. The disparities of health indicators exist in areas of different income and different education level.
By analyzing the relationships among the 31 indicators abstracted from the National health service reports 2003, it is found that the indicators are closely correlated. The regression analysis indicates that the social economic status influences health outcomes, non-medicine health determinants and health services.
The indicator is a special data element generated by other data elements. The description method has been developed to metadata of public health indicator. The study of metadata of indictor is the process of indicator standardization.
Conclusions: The conceptual framework of public health service evaluation was first developed after extensive literature review and expert consultation and its domain and sub-domains are described thoroughly.This framework has been validated by public health information personnel and experts in the public health field. The conceptual framework plays an important role in directing establishment of indicator system and guiding the data analysis. The description method of public health indicator will improve the standardization of public health indictors.
目的:探索公共卫生服务评价概念框架建立的理论和方法,构建公共卫生服务评价概念框架,确定框架的结构(维度、子维度)及其构成部分的关联关系;根据概念框架建立公共卫生服务评价的指标体系;确定公共卫生服务指标元数据的描述方法。
方法:在卫生服务质量评价模型和健康影响因素模型的基础上,通过文献分析法建立概念框架的初始模型,经专家会议论证、修订,确定概念框架的结构、维度和子维度。以问卷调查的方式,请公共卫生信息会议参加者和公共卫生领域的专家进行概念框架的评价。根据概念框架的研究成果,依据概念框架的维度和子维度构成和指标的选择标准,确定公共卫生服务评价指标体系的初始问卷,通过Delphi专家问卷咨询法,确定指标体系。利用国家第三次卫生服务调查分析报告的数据,依据概念框架对数据再分析。并通过卫生服务数据,了解卫生服务指标间的相互关系。
结果:提出了健康结果、健康的非医学因素、公共卫生服务提供、支撑体系四个维度和十五个子维度组成的概念框架,确定了维度的定义和内涵,维度间和维度内子维度间的相互关系。健康结果维度包括完满健康、健康状态、人体功能和死亡四个子维度;非医学健康因素的4个子维度是健康行为、社会经济因素、生物遗传因素和环境因素;公共卫生服务提供维度包括疾病预防控制、卫生监督检测、健康教育和妇幼保健四个横向维度,和有效性、及时性、安全性、可接受性、连续性、反应性、可及性、适宜性和效率的纵向维度;支撑体系维度包括机制保障、资源保障和政策法规保障。健康结果反映公共卫生服务的结果,健康的非医学因素反映公共卫生服务的中间结果,公共卫生服务反映公共卫生服务的过程,而支撑体系反映公共卫生系统的结构特征。公共卫生服务的公平性反映在公共卫生服务的全过程,框架中将其作为和其他四个维度的交叉维度,而不作为一个单独的维度。概念框架得到了公共卫生信息与会者和公共卫生领域专家的认可。
共遴选了26位国内知名的公共卫生学者和专家参加了两轮指标体系Delphi法专家问卷咨询调查,第一、二轮咨询调查的专家积极系数分别为0.71和0.94。根据专家咨询调查的分析结果确定了由62个指标构成的指标体系,指标体系的协调系数表明专家咨询有较好的一致性。
利用国家卫生服务调查的聚合数据,分析了从分析报告中抽取的31个指标间的相互关系。结果表明:健康结果、健康的非医学因素、公共卫生服务和支撑体系指标间存在着复杂的相关关系。影响因素线性多元回归的分析结果表明,社会经济因素对健康结果、健康行为和卫生服务的利用有重要的影响。通过比较不同类别地区卫生服务评价指标发现,如城市和农村间,不同收入水平和教育程度的地区间卫生服务指标间存在显著的差异。
指标是从数据元产生的新的、特殊的数据元。建立在数据元元数据研究的基础上,结合公共卫生指标的特点,本研究建立了指标元数据的描述方法。这将有助于指标的标准化。
结论:建立在卫生服务质量评价和健康影响因素模型基础上,经大量文献分析和专家咨询,在国内第一次提出了公共卫生服务概念框架,并对概念框架的维度和子维度进行了详细的描述。框架得到了公共卫生信息工作者和公共卫生领域专家学者的一致认可。对于构建指标体系、指导数据分析有非常重要的意义。公共卫生指标元数据的描述方法将有利于指标的标准化。
Background: The rapid social and economical development and increasing sense of health protection have made people care more about their health problem and public health. The government, community, and society know about public health service and the quality of public health services, and it requires an indicator system comprised of inherently connected indicators to evaluate the quality of public health correctly and comprehensively. The indicator system is more than just a collection of indicators. It should be able to measure its distinct components of the system and also provides information about how the individual components work together to produce the overall effect. In other words, the whole of the information provided by a system of indicators is greater than the sum of its parts. After many years of public health research and practice, we have compiled a set of indicators and developed an indicator system to reflect public health service. However, most of indicator systems in the public health field were built based upon the tasks and components of public health department. These indicator systems do not have solid conceptual framework.
The development of the conceptual framework for public health service will help to build indicator system which is well-structured and evenly distributed. At the same time the conceptual framework will provide a scientific classification method for indicator and make it easy to explain the indicator. The conceptual framework can help to generate systematic and comprehensive information, which can be used to formulate public health policy. It is found that the same indicator sometimes has many different definitions. The lack of standardization for indicator make it difficult for data exchange and data integration and also affect the development of public health policy, therefore, the study of indicator metadata have been emphasized much.
Objectives: To explore the theory and method of developing conceptual framework for public health service, to establish the conceptual framework of public health service and to define the structure and components of the framework and the relationships among them. To build indicator system of public health service based upon the framework. To establish the methods of defining the metadata of indicator and indicator system.
Methods: The initial conceptual framework was constructed on the basis of the results of literatures review and concept analyses. The development of conceptual framework is based upon health determinant model and the theory of healthcare quality evaluation. The initial framework has been modified based upon the suggestions given by experts during the expert meeting to validate the framework. Some domains and sub domains were removed and some domain and sub domains are redefined. The modified framework was evaluated by public health information conference attendee and experts and scholars in public health area via a questionnaire survey.
The initial indicator questionnaire was drafted according to the newly created conceptual framework and the selecting criteria of indicators are followed. The two-round Delphi survey was conducted to establish the indicator system for public health service. The data from analysis report of national health services survey in 2003 was analyzed according to the framework. The abstracted 31 indicators were utilized to understand the complicated relationships between and within domains (or sub domains)
Results: A conceptual framework consisting of four domains and 15 sub-domains is developed. The 4 domains are health status, non-medical health determinants, provision of public health service, and the supporting system. The health outcome includes three sub-domains of wellbeing, health status, functional status, and death; Non-medicine health determinants domain consists of health behavior, biological and genetic factors, social and economic factors and physical environmental factors; public health domain includes two dimensions. Vertical domain is made up of effectiveness, timeliness, safety, accessibility, continuity, responsibility, appropriateness, and efficiency; and horizontal domains includes disease prevention and control, health education, Children and maternity care and health protection. The supporting system has three sub-domains. They are resource assurance, mechanism assurance and regulation and policy assurance. The complicated relationship between these domains is also described. The notion of equity spans all dimensions of the framework, and can apply equally to any construct or dimension. Therefore equity is not included as a fifth dimension of the Health Indicators Conceptual framework, but is presented as a crosscutting element of the framework that applies to each of the four dimensions.
The structure and components of the conceptual framework were highly recognized by public health information conference attendee and experts in public health fields. Twenty-Four (26) experts and scholars working in public health area were selected to participate in two-round Delphi questionnaire survey. The active coefficients of first and second round are 0.71 and 0.94, respectively. The final indicator system has 62 indicators. The results of Kendall's W test shows the higher concordance in both rounds of consultation.
The comparisons of health indicators abstracted from health service report support that there are tremendous differences between the urban population and rural population. The disparities of health indicators exist in areas of different income and different education level.
By analyzing the relationships among the 31 indicators abstracted from the National health service reports 2003, it is found that the indicators are closely correlated. The regression analysis indicates that the social economic status influences health outcomes, non-medicine health determinants and health services.
The indicator is a special data element generated by other data elements. The description method has been developed to metadata of public health indicator. The study of metadata of indictor is the process of indicator standardization.
Conclusions: The conceptual framework of public health service evaluation was first developed after extensive literature review and expert consultation and its domain and sub-domains are described thoroughly.This framework has been validated by public health information personnel and experts in the public health field. The conceptual framework plays an important role in directing establishment of indicator system and guiding the data analysis. The description method of public health indicator will improve the standardization of public health indictors.
引文
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