山东省流动人口肺结核病人求医行为及治疗管理现状与对策研究
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摘要
研究背景
20世纪80年代后,结核病疫情有所回升,再次成为全球关注的公共卫生焦点问题之一。中国是22个结核病高负担国家之一,结核病人数仅次于印度而居世界第二位。近年来,随着DOTS策略的实施及各级政府的日渐重视,中国结核病疫情得到一定程度控制。尽管如此,在结核病控制领域,中国仍面临着诸多严峻挑战,流动人口结核病控制就是面临的重要挑战之一。
2009年,中国流动人口数量已升至2.11亿。未来30年,中国将形成5亿城镇人口、5亿流动迁移人口、5亿农村人口“三分天下”的格局。由于经济收入低、工作和生活条件差、文化程度低、健康观念差等原因,流动人口结核病疫情相对较为严重。流动人口数量的迅速增加是结核病疫情再次攀升的重要原因之一。流动人口肺结核病人多居无定所,流动性大,难以坚持规则治疗,治疗管理相对困难,造成耐药结核病比例增加,并增加传播的几率,给区域结核病控制造成诸多困难。流动人口结核病控制已经成为中国结核病防治规划中亟待解决的问题之一。
当前结核控制主要依靠及早发现病例和完治病人,以阻断传播和减少发病。早发现要求病例在接触卫生系统后能及时被识别为可疑症状者并迅速转诊到结防机构以确诊并治疗。病人求医过程的任何环节延误将增加其传播的几率,导致病人死亡率的提高。因此,能否及时发现病人是流动人口结核病控制工作成败的关键环节之一。病人被确诊后,需要对活动性肺结核病人进行治疗管理,对涂阳肺结核病人进行重点管理,以最大限度地确保病人完成规则疗程。若治疗管理不善,会降低病人治疗成功率,导致耐药病人数量增加,降低病人治愈率,并进一步增加社会传播几率。因此,能否对病人治疗实施有效管理是流动人口结核病控制又一关键过程。
但是,现有研究中缺乏对流动人口求医行为及相关因素的系统研究,未见对流动人口求医行为路径的分析,也未见对流动人口肺结核病人治疗管理领域的专题调查。为此,本研究选择流动人口肺结核病病人诊治过程中求医行为及治疗管理两个重要过程进行深入研究。
研究目的
本研究的总体目标是探索流动人口肺结核病人求医行为障碍、治疗管理现状及存在问题,为提高病人发现及治疗管理效果提供相关政策依据。具体研究目的包括：研究流动人口肺结核病人求医行为及其障碍因素,构建流动人口肺结核病人求医行为模型；研究流动人口肺结核病人治疗管理现状及影响因素；评价流动人口肺结核病人求医行为及治疗管理中存在的主要问题；针对性地提出促进流动人口肺结核病人及时发现及治疗管理的策略。
研究方法
本研究采用定量、定性调查,并结合文献资料,从多角度分析流动人口肺结核病人求医行为、治疗管理现状及存在问题。
综合考虑调查前1年内登记涂阳流动人口病人数量、经济水平及地理位置等方面因素,在山东省抽取了7个地级市的12个县(市、区)作为样本研究现场。选择在12个县(市、区)结核病防治机构登记的正在接受治疗或调查前半年内完成治疗的流动人口肺结核病人作为研究对象,共对314名符合标准的病人进行了调查。此外,还从12个样本地区中选择6个县(市、区)开展了定性访谈,定性访谈对象包括选中6个县(市、区)结核病防治机构负责人、大夫、乡镇(街道)医生、卫生所(室)医生及流动人口肺结核病人,以了解他们对流动人口肺结核病人发现(求医)障碍及治疗管理问题的认识。
研究资料来源包括统计年鉴资料、文献资料、病人面对面问卷调查以及关键人物定性访谈。现场资料收集工作由经培训合格的山东大学公共卫生学院部分老师和研究生及山东省结核病防治中部分工作人员承担完成。使用EPIDATA6.04软件建库录入资料,采用SPSS13.0软件分析资料,采用描述性统计分析、t检验、F检验、Mann-Whitney U、Kruskal -Wallis H秩和检验等方法进行单因素分析,采用logistic回归方法进行多因素分析。采用描述性分析方法分析定性数据。
主要研究结果
对流动人口肺结核病人结核核心知识点认知分析结果显示,“肺结核病的传播途径”、“肺结核病是由什么原因引起”、“肺结核病主要症状”、“是否知道国家对肺结核病人治疗的免费政策”等知识点知晓率均低于75%,90%以上病人认为结核病是可以治愈的；文化程度、家庭类型等是影响病人结核病认知水平的因素。
流动人口肺结核病人就诊延迟天数中位数为10天,平均数为18.84天,就诊延迟率为40.8%；确诊延迟天数中位数为8天,平均数为15.62天,确诊延迟率为44.6%；治疗延迟天数中位数为1天,平均数为2.51天,治疗延迟率为65.6%。家庭总收入低的病人就诊延迟比例高于家庭总收入高的病人；来自贫困/低保户病人就诊延迟比例高于非贫困/低保户病人；每周工作天数在5天以上的病人就诊延迟比例高于工作5天及以下病人；有医疗保险的病人就诊延迟比例低于无医疗保险病人；到达最近乡镇/街道卫生院时间在30分钟以内的病人就诊延迟比例低于30分钟及以上病人；初始症状轻度和中度的病人就诊延迟比例高于初始症状重度病人；结核病认知水平低的病人就诊延迟比例高。低年龄组病人确诊延迟比例高于高年龄组病人；每周工作天数在5天以上的病人确诊延迟比例高于工作5天及以下病人；距离结防机构较近的病人确诊延迟比例低于距离在20公里及以上的病人；轻度初始症状病人确诊延迟比例高于重度初始症状病人；首诊单位为卫生所(室)的病人确诊延迟比例高于卫生院及其以上级别医疗卫生机构；经济状况差的病人确诊延迟比例高。个人年收入低的病人治疗延迟比例高于年收入高的病人；有亲人陪伴的病人出现治疗延迟比例低于无亲人陪伴病人；确诊症状为中度、重度病人出现治疗延迟比例高于确诊症状轻度病人；与初始症状相比,确诊时症状加重的病人出现治疗延迟的比例比未加重病人低；认为结核病可以治愈的病人出现治疗延迟比例低于认为不可以治愈的病人；知道结核病免费治疗政策病人出现治疗延迟比例低于不知道免费政策病人。
咳嗽是近70%流动人口肺结核病人主要的初始症状。有48.73%的病人在出现初始症状后选择县级及以上机构首诊,32.8%的病人选择卫生所(室)首诊。文化程度、家庭债务情况以及初始症状与流动人口肺结核病人首诊机构选择有关。小学及以下和初中文化程度患者选择县级及以上医院首诊比例低于高中文化程度者；家庭有债务的病人去卫生所(室)首诊比例高于无债务患者；无咯血/血痰者选择卫生所(室)首诊比例高于咯血/血痰者。
病人到达结核病防治所前(含结防所),最少就诊1次,最多就诊9次,平均就诊2.96次,平均就诊了2.44个医疗卫生机构。病人求医过程就诊机构主要涉及卫生所(室)、乡镇(街道)卫生院、县(市、区)医院、县(市、区)以上医院、结防所等。病人首诊机构与病人求医过程的复杂程度相关。病人求医路径与病人确诊延迟相关,随着整个求医路径涉及机构数量的增加,确诊延迟天数(中位数)有延长的趋势。
病人化疗前接受宣传教育率为81.5%。对病人督导管理方式分析结果显示,全程督导化疗占58.3%,强化期督导化疗占13.7%,全程管理占1.0%,自服药比例为27.1%。病人督导化疗率为72.0%,供方因素是影响病人督导化疗的重要因素；此外,病人工作情况(包括工作类型、工作时间)也是影响病人接受督导化疗的因素。
有92.0%的患者自己保管药品,有8.0%的患者将药物交给基层医生保管。医生趋利动机及病人对歧视的惧怕是造成医生保管药物比例低的原因。37.6%的病人表示在治疗过程中有县级结防机构医生到住处访视,39.8%的病人表示在治疗过程中有基层防保医生到住处访视。两级医生访视比例均较低,可能的原因是县乡两级医生人员不足及经费有限。
有15.9%的病人在治疗期间出现服药不依从现象。婚姻状况、化疗前是否接受宣传教育、免费政策对治疗激励性评价、督导管理人员与流动人口肺结核病人服药依从性相关。在婚病人服药依从率低于未婚病人；化疗前未接受宣传教育病人服药依从率低于接受宣传教育者；认为免费政策对治疗没有激励作用的病人服药依从率低于认为有激励作用者；由基层医生监督的患者服药依从率显著高于无人监督者。在已经终止治疗的病人中,治疗成功率为80.5%。知道结核病治疗疗程的病人治疗成功率高于不知道结核病治疗疗程的病人。
结论与政策建议
流动人口肺结核病人结核知识认知水平有待进一步提高,病人文化程度及家庭类型等是影响其认知水平的因素。确诊延迟与就诊延迟对延迟发现有近乎同等的影响,确诊延迟率略高于就诊延迟率。经济贫困是制约流动人口肺结核病患者求医行为的重要障碍因素之一；此外,工作时间、初始症状严重程度、卫生服务地理可及性等因素对延迟发现也有重要影响。流动人口肺结核病人求医行为过程复杂,需要多次就诊、经历多家医疗机构才能获得规则的抗结核治疗。在首诊时,卫生所(室)将病人诊断为疑似结核病的比例非常低；文化程度、家庭债务情况以及咯血／血痰症状与流动人口肺结核病人首诊机构选择有关。对流动人口开展常规结核病健康教育有利于结核病人及时发现。未接受宣传教育的病人服药依从性显著低于接受宣传教育的病人,知道结核病规则治疗疗程的病人完成治疗的比例高。有27.1%病人无任何督导管理,而是自服药。自服药病人治疗效果要低于实施督导管理的病人。基层医生在病人发现中扮演着非常重要的角色,但事实上并未能发挥其应有的作用。流动人口肺结核病人中,92.0%病人的药品由病人自己保管；两级医生访视比例均较低。流动人口肺结核病人中,有16.0%的病人在整个治疗过程中未能坚持规律服药。
为提高流动人口病人发现及治疗管理效果,提出如下建议：(1)加大流动人口结核病控制专项经费倾斜性投入力度,对投入资金加以监管,提高资金使用效率；(2)采取综合帮困措施,打破“贫困-结核病卫生服务利用低下-健康损伤-更贫困”的恶性循环,提高贫困流动人口结核病卫生服务可及性；(3)加强基层医生培训和激励,充分发挥基层医生在病人发现及治疗管理中的作用；(4)开展流动人口针对性健康教育,包括：加强流动人口流出地宣传教育,利用流动比较集中时期开展健康教育,开发简易健康教育资料,开展以雇主为中心的健康教育,化疗前100%健康教育；(5)加强流动人口肺结核病人自我管理指导。
创新性及不足
本研究的创新性主要体现在：
(1)目前国内外未见有对流动人口肺结核病人诊治全过程的系统性研究。本研究系统分析了流动人口从出现症状到求医到治疗全过程的现状及存在问题,并探索了相应障碍因素,为及早发现流动人口肺结核病人、改善其治疗管理效果提供了重要依据；
(2)本研究在求医行为障碍因素分析及路径描述的基础上,首次构建了流动人口肺结核病人求医行为决定因素模型及路径模型,为全面、系统了解流动人口肺结核病人求医行为过程提供了依据；
(3)本研究在描述流动人口肺结核病人延迟治疗时,为了解病人确诊后治疗的及时性,尝试使用了治疗延迟的指标,在描述病人治疗管理现状时,引入了流动人口肺结核病人化疗前接受专业人员健康教育率指标,并从需方角度探索了治疗管理相关影响因素。
本研究不足：
(1)本研究是以样本地区结核病防治机构为基础的研究,所有接受调查的病人均是结核病防治机构登记的病人。因此,本研究可能存在一定的选择偏性。
(2)本研究系回顾性研究,尽管在现场调查中,我们已采取了各种措施以控制质量,但回忆偏性在所难免,这可能会对研究结果造成一定的影响。
此外,部分病人在接受调查时,可能会因为理解偏颇或不愿意透露有关敏感信息,对病人收入及支出信息的真实性可能会产生影响。
Backgrounds
In the late 1980s, the increasing incidence of tuberculosis (TB) brought it back to be one of the foci of public health arousing global concerns. As one of the 22 countries of heavy disease burden of TB in the world, China ranks the second just following the India in terms of the number of TB patients.In recent years, with the implementation of DOTS strategy and more attention of government at all levels, epidemic situation of TB in China had been curbed to a certain extent. Even so, China is still facing a good deal of severe challenges, one of which is TB control among migrants in China. In 2009, the number of floating population in China had risen to 211 million. In next 30 years, China will form a "trisection" pattern of 500 million urban populations,500 million floating population and 500 million rural populations. Because of low income, poor working and living conditions, low education level, and weak awareness of health etc., TB epidemic situation among floating population is relatively serious. Rapid increase in the number of floating population is one of the most important reasons of TB epidemic rise. No fixed homes for most of floating population, high mobility, and difficulties in adhering to regular treatments and in treatment management result in increasing proportion of drug-resistant TB and risk of transmission, which brings out many obstacles to the regional TB control. TB control among migrants has become an urgent problem to solve in TB Control Programme of China.
Currently, TB control relies mainly on early detection of cases and completed treatment so as to cut transmission and reduce morbidity. Early detection requires a timely manner of identifying patients as suspicious TB cases and a rapid referral to TB dispensaries for diagnosis and treatment after their involvement in health system. Delays occurring in any part of health-seeking process would increase the probability of TB transmission and eventually result in high mortality. Therefore, the ability to detect TB patients among floating population is a key to the success of TB control. After diagnosis, treatment management of active tuberculosis patients and strengthened treatment management of smear-positive patients are necessary, so as to ensure patients complete treatment, otherwise, the success rate of treatment and cure rate would drop, number of drug-resistant TB cases would increase, which furthermore results in high risk of social transmission. Therefore, the effective management of patient treatment is another essential process in TB control among migrants.
However, after searching for existing literature, we found no systematic research on behaviors and pathways of migrants'health seeking and relevant factors, as well as special survey on migrant TB patients'treatment management. Therefore, we selected two important processes-behavior of health seeking and treatment management-mentioned above as research focuses.
Objectives
The general objective of this study is to explore current situation and problems of tuberculosis patients'health-seeking behavior and treatment management among migrants, in order to put forward some suggestions to improve TB case finding and treatment management effectiveness. The specific objectives include:identifying health-seeking behavior and its obstacles; establishing patients health-seeking behavior model based on identifying influencing factors of TB patients health-seeking behavior; evaluating on current situation of TB patients treatment management and relevant factors; identifying key problems in TB patients health-seeking behavior and treatment management among migrants; making strategic suggestion to promote TB case early detection and improve treatment management effectiveness.
Methods
Quantitative methods, qualitative methods and literature analysis were comprehensively used in this study so as to analyze the health-seeking behavior and treatment management and its problems to form a multi-angle research.
A total of 12 counties (districts) in 7 cities of Shandong province were selected as study sites according to the economic level and geography distribution and the number of smear-positive migrants TB cases registered during the past year. The smear-positive migrants TB cases registered in the 12 sampling counties (districts) TB dispensaries were recruited into the study, including 314 patients who were being treated and had completed normal treatment within 6 months.. Meanwhile, we carried out focus group discussion and in-depth discussion in 6 sites from the 12 sampling counties (districts). And directors, doctors of TB dispensaries, doctors of grass-roots medical institutions and migrants TB patients of the 6 sampling counties (districts) were interviewed as key informants to tell us their cognition on constraints of TB cases health-seeking behavior and problems existed in TB cases treatment management.
The data of this study mainly source from Shandong Statistics Yearbook, literature review, face-to-face interview of migrants TB cases and key informants discussion. The researchers and graduate students from School of public health of Shandong University, and some staff from Shandong Centre for TB Prevention and Control undertook the task of data collection. The data were entered using software EPI Data 6.04, then analyzed by using software SPSS 13.0. The methods of descriptive analysis, t-test, analysis of variance, Mann-Whitney U test, Kruskal-Wallis H test and multinomial logistic regression were applied in the research. The qualitative data were analyzed by descriptive analysis and case analysis.
Main results
TB core knowledge points among migrants TB cases were as follows:"what are the transmissions of tuberculosis", "what causes TB", "what are main symptoms of tuberculosis ", and "TB free treatment policy". TB cases awareness rate of all the four points were less than 75%. Over 90% of patients hold the view that TB could be curative. Education level and family type (from rural areas or urban areas) affected the level of migrants TB cases cognition.
The median of patient delay for migrants TB patients was 10 days, with an average of 18.84 days. Patients with a patient delay over 14 days accounted for 40.8%. The median of diagnosis delay was 8 days, with an average of 15.62 days. Patients with a diagnosis delay over 14 days accounted for 44.6%. The median of treatment delay was 1 days, with an average of 2.51 days. Patients with a treatment delay over 1 day accounted for 65.6%. TB patients with low household income, from poor/minimum living households, working over 5 days per week, without health insurance, taking over 30 minutes to the nearest township/street hospitals, with mild and moderate initial symptoms, with poor cognition on TB experienced longer patient delay. TB patients from younger group, working over 5 days per week, with a closer distance to local TB dispensaries, with mild initial symptoms, with first visit to clinics,under poor economic conditions experienced longer diagnosis delay. TB patients with low individual annual income, with accompany of relatives, with moderate and severe symptoms when diagnosed, with more severe symptoms when diagnosed compared with the initial symptoms, with the knowledge that TB cannot be cured and with little knowledge about TB free treatment policy experience longer treatment delay.
Nearly 70% of patients had cough at onset.48.73% of them selected health institutions of county level and above as their first visit health facilities, and 32.8% of them selected the grass-root clinics as their first visit health facilities. Education level, household debt status and initial symptom severity were factors affecting patients' selection of first visit health institutions. Patients with education level of junior high school and above preferred to go to health institutions of county level and above as their first visit health facilities, the patients with debt preferred to go to grass-root clinics as their first visit health facilities. The patients with initial symptoms of hemoptysis or bloody sputum preferred to go to county health institutions and above as their first visit health facilities.
Before the arrival at TB dispensaries (including the county TB dispensaries), TB patients'visit times ranged from 1 to 9, an average of 2.96 visits. Without considering repeated visits to the same health institutions, the average of health institutions visited was 2.44. The facilities involved in the process of migrant patients health-seeking behavior included health clinics, township (community) health centers, county (district) hospitals and above, and other hospitals or TB dispensaries, etc. TB patients'first visit health facilities had impact on the complexity of the process of health-seeking behavior. Patients'health-seeking pathways were associated with diagnosis delay. With the increase in the number of health facilities involved in the pathway, the median of diagnosis delay extended.
The number of patients who received TB-related health education prior to the chemotherapy accounted for 81.5%.58.3% of the patients experienced whole-process supervisory management,13.7% monitoring management during strengthening period of chemotherapy,1.0% whole-process management, and 27.1% self-medication. Patient supervisory management rate was 72.0%. Supply side factors were associated with patient supervisory management rate. Additionally, patients'working condition (including the type of occupation, working hours) was also an important factor that affected patients' supervisory management rate.
92.0% of patients kept anti-TB drugs by themselves,8.0% of patients gave their drugs to local primary physicians to keep. Primary physicians'pursuits of profits and patients' fear of discrimination caused the lowly drug-keeping percentage of primary physicians. 37.6% of the patients got visits to the residence from doctors in county TB dispensaries in the process of treatment.39.8% of the patients got visits to the residence from doctors of grass-root preventive doctors in the process of treatment. The low visit rate from county and township levels doctors may be due to lack of health personnel and limited funds.
15.9% of patients experienced non-compliance of using anti-TB drug in the process of treatment. Marital status, whether received TB-related health education prior to the chemotherapy or not, patients evaluation on the inventiveness of free treatment policies, treatment supervisor had significant relation to migrant patients compliance in using anti-TB drug. Married patients were easier to take drug regularly than single patients, patients who received TB-related health education prior to the chemotherapy had better compliance in drug-taking behavior than those who didn't, patients who thought the free treatment policy incentive had better compliance in drug-taking behavior than those who didn't, and patients who were supervised by clinic doctors were easier to take drug regularly than patients without supervisor. Among patients who had completed TB treatment, success rate of treatment was 80.5%. Patients who knew TB treatment regulations had higher success rate of treatment than those who didn't.
Conclusions and Recommendations
Migrant TB patients'cognition level on TB was rather low, and should be further enhanced. Patient educational level and family types were the factors that affected their cognition level. Diagnosis delay and patient delay had nearly same impact on delayed detection, and diagnosis delay rate was slightly higher than patient delay rate. Poverty was a crucial constraint for TB patients'access to health service among migrants, hi addition, working time, initial symptom severity and geographic accessibility to health service were factors influencing delayed detections. The process of health-seeking behavior among migrant TB patients was very sophisticated, requiring many visits(considering repeated visits to the same health institution) to medical institutions before accepting regular anti-TB treatment. In the first visit, the rate of diagnosing TB patients as suspected one by grass-root clinic doctors was low. Educational level, household debt status and initial symptom severity were factors affecting patients first visit selection of health institutions. To carry out TB-related health education prior to the chemotherapy was conducive to early detection of TB patients, high compliance in using anti-TB drug and high success rate of treatment.27.1% of patients took the medication without monitoring, which had negative effects on treatment outcome. Grass-root clinic doctors played a more important role in TB cases detection, but in fact failed to.92.0% of patients kept the anti-TB drug by themselves. The visit rate to patients'residence of doctors at county and township levels was rather low.16.0% failed to adhere to the regulation of using anti-TB drug in the whole process of treatment.
We put forward the following specific recommendations for the improvement of early TB case detection and treatment management effectiveness among migrants:(1) To increase the financial input of special funds for TB control among migrants, and strengthen the monitoring of funds to improve capital efficiency; (2) To adopt comprehensive measures helping the vulnerable poor to break the circle of "poverty-low utilization of TB health services-health damage-more poverty" so as to improve migrants'TB cases health services accessibility; (3) To strengthen training of primary care doctors and improve incentive mechanism, and give them more chances to play their full role in early case detection and treatment management; (4) To carry out targeted health education among floating population, including:strengthening propaganda and education on the floating population before their flowing out from their hometowns, carrying out health education during concentrated period of flowing, developing simple health education materials, carrying out the employer-centered health education, implementing 100% health education before chemotherapy; (5)To strengthen guidance on patients'self-management in the process of treatment.,
Innovations and Limitations
Innovations
(1) There lacks systematic researches concerning the overall process of diagnosis and treatment of TB patients among floating population at home and abroad. The study analyzes current situation and existing problems of the overall process from observable symptom to treatment among floating population systematically, and explores corresponding barriers, in order to provide essential suggestions to early detection and enhancing efficiency of treatment management;
(2) Based on the description of barriers of behaviors and path of seeking medical services, the study initially establishes the models of determinants and path of TB patients among floating population, in order to enhance the comprehensive and systematic understanding of the process of their seeking medical services;
(3) This study tries to employ index of delayed treatment so as to grasp the condition of timeliness of receiving treatment after diagnosis, introduces the rate of health education before regular treatment as an indicator to reflect the current situation of treatment management and explores relevant factors of it from the perspective of health service consumers.
Limitations
(1) There might be selective bias in the study due to the fact that our interviewees are all registered patients in prophylactic-therapeutic institutions.
(2) The study is retrospective. Although various measures were taken to control the survey's quality in the field, recall bias, bound to impose a certain effect on the study, is unavoidable.
In addition, when interviewed, patients might not tend to provide real sensitive information owing to privacy and biased understanding, in the sense that there is likely to be discrepancy between collected data and real condition in terms of income and expenditure.
20世纪80年代后,结核病疫情有所回升,再次成为全球关注的公共卫生焦点问题之一。中国是22个结核病高负担国家之一,结核病人数仅次于印度而居世界第二位。近年来,随着DOTS策略的实施及各级政府的日渐重视,中国结核病疫情得到一定程度控制。尽管如此,在结核病控制领域,中国仍面临着诸多严峻挑战,流动人口结核病控制就是面临的重要挑战之一。
2009年,中国流动人口数量已升至2.11亿。未来30年,中国将形成5亿城镇人口、5亿流动迁移人口、5亿农村人口“三分天下”的格局。由于经济收入低、工作和生活条件差、文化程度低、健康观念差等原因,流动人口结核病疫情相对较为严重。流动人口数量的迅速增加是结核病疫情再次攀升的重要原因之一。流动人口肺结核病人多居无定所,流动性大,难以坚持规则治疗,治疗管理相对困难,造成耐药结核病比例增加,并增加传播的几率,给区域结核病控制造成诸多困难。流动人口结核病控制已经成为中国结核病防治规划中亟待解决的问题之一。
当前结核控制主要依靠及早发现病例和完治病人,以阻断传播和减少发病。早发现要求病例在接触卫生系统后能及时被识别为可疑症状者并迅速转诊到结防机构以确诊并治疗。病人求医过程的任何环节延误将增加其传播的几率,导致病人死亡率的提高。因此,能否及时发现病人是流动人口结核病控制工作成败的关键环节之一。病人被确诊后,需要对活动性肺结核病人进行治疗管理,对涂阳肺结核病人进行重点管理,以最大限度地确保病人完成规则疗程。若治疗管理不善,会降低病人治疗成功率,导致耐药病人数量增加,降低病人治愈率,并进一步增加社会传播几率。因此,能否对病人治疗实施有效管理是流动人口结核病控制又一关键过程。
但是,现有研究中缺乏对流动人口求医行为及相关因素的系统研究,未见对流动人口求医行为路径的分析,也未见对流动人口肺结核病人治疗管理领域的专题调查。为此,本研究选择流动人口肺结核病病人诊治过程中求医行为及治疗管理两个重要过程进行深入研究。
研究目的
本研究的总体目标是探索流动人口肺结核病人求医行为障碍、治疗管理现状及存在问题,为提高病人发现及治疗管理效果提供相关政策依据。具体研究目的包括：研究流动人口肺结核病人求医行为及其障碍因素,构建流动人口肺结核病人求医行为模型；研究流动人口肺结核病人治疗管理现状及影响因素；评价流动人口肺结核病人求医行为及治疗管理中存在的主要问题；针对性地提出促进流动人口肺结核病人及时发现及治疗管理的策略。
研究方法
本研究采用定量、定性调查,并结合文献资料,从多角度分析流动人口肺结核病人求医行为、治疗管理现状及存在问题。
综合考虑调查前1年内登记涂阳流动人口病人数量、经济水平及地理位置等方面因素,在山东省抽取了7个地级市的12个县(市、区)作为样本研究现场。选择在12个县(市、区)结核病防治机构登记的正在接受治疗或调查前半年内完成治疗的流动人口肺结核病人作为研究对象,共对314名符合标准的病人进行了调查。此外,还从12个样本地区中选择6个县(市、区)开展了定性访谈,定性访谈对象包括选中6个县(市、区)结核病防治机构负责人、大夫、乡镇(街道)医生、卫生所(室)医生及流动人口肺结核病人,以了解他们对流动人口肺结核病人发现(求医)障碍及治疗管理问题的认识。
研究资料来源包括统计年鉴资料、文献资料、病人面对面问卷调查以及关键人物定性访谈。现场资料收集工作由经培训合格的山东大学公共卫生学院部分老师和研究生及山东省结核病防治中部分工作人员承担完成。使用EPIDATA6.04软件建库录入资料,采用SPSS13.0软件分析资料,采用描述性统计分析、t检验、F检验、Mann-Whitney U、Kruskal -Wallis H秩和检验等方法进行单因素分析,采用logistic回归方法进行多因素分析。采用描述性分析方法分析定性数据。
主要研究结果
对流动人口肺结核病人结核核心知识点认知分析结果显示,“肺结核病的传播途径”、“肺结核病是由什么原因引起”、“肺结核病主要症状”、“是否知道国家对肺结核病人治疗的免费政策”等知识点知晓率均低于75%,90%以上病人认为结核病是可以治愈的；文化程度、家庭类型等是影响病人结核病认知水平的因素。
流动人口肺结核病人就诊延迟天数中位数为10天,平均数为18.84天,就诊延迟率为40.8%；确诊延迟天数中位数为8天,平均数为15.62天,确诊延迟率为44.6%；治疗延迟天数中位数为1天,平均数为2.51天,治疗延迟率为65.6%。家庭总收入低的病人就诊延迟比例高于家庭总收入高的病人；来自贫困/低保户病人就诊延迟比例高于非贫困/低保户病人；每周工作天数在5天以上的病人就诊延迟比例高于工作5天及以下病人；有医疗保险的病人就诊延迟比例低于无医疗保险病人；到达最近乡镇/街道卫生院时间在30分钟以内的病人就诊延迟比例低于30分钟及以上病人；初始症状轻度和中度的病人就诊延迟比例高于初始症状重度病人；结核病认知水平低的病人就诊延迟比例高。低年龄组病人确诊延迟比例高于高年龄组病人；每周工作天数在5天以上的病人确诊延迟比例高于工作5天及以下病人；距离结防机构较近的病人确诊延迟比例低于距离在20公里及以上的病人；轻度初始症状病人确诊延迟比例高于重度初始症状病人；首诊单位为卫生所(室)的病人确诊延迟比例高于卫生院及其以上级别医疗卫生机构；经济状况差的病人确诊延迟比例高。个人年收入低的病人治疗延迟比例高于年收入高的病人；有亲人陪伴的病人出现治疗延迟比例低于无亲人陪伴病人；确诊症状为中度、重度病人出现治疗延迟比例高于确诊症状轻度病人；与初始症状相比,确诊时症状加重的病人出现治疗延迟的比例比未加重病人低；认为结核病可以治愈的病人出现治疗延迟比例低于认为不可以治愈的病人；知道结核病免费治疗政策病人出现治疗延迟比例低于不知道免费政策病人。
咳嗽是近70%流动人口肺结核病人主要的初始症状。有48.73%的病人在出现初始症状后选择县级及以上机构首诊,32.8%的病人选择卫生所(室)首诊。文化程度、家庭债务情况以及初始症状与流动人口肺结核病人首诊机构选择有关。小学及以下和初中文化程度患者选择县级及以上医院首诊比例低于高中文化程度者；家庭有债务的病人去卫生所(室)首诊比例高于无债务患者；无咯血/血痰者选择卫生所(室)首诊比例高于咯血/血痰者。
病人到达结核病防治所前(含结防所),最少就诊1次,最多就诊9次,平均就诊2.96次,平均就诊了2.44个医疗卫生机构。病人求医过程就诊机构主要涉及卫生所(室)、乡镇(街道)卫生院、县(市、区)医院、县(市、区)以上医院、结防所等。病人首诊机构与病人求医过程的复杂程度相关。病人求医路径与病人确诊延迟相关,随着整个求医路径涉及机构数量的增加,确诊延迟天数(中位数)有延长的趋势。
病人化疗前接受宣传教育率为81.5%。对病人督导管理方式分析结果显示,全程督导化疗占58.3%,强化期督导化疗占13.7%,全程管理占1.0%,自服药比例为27.1%。病人督导化疗率为72.0%,供方因素是影响病人督导化疗的重要因素；此外,病人工作情况(包括工作类型、工作时间)也是影响病人接受督导化疗的因素。
有92.0%的患者自己保管药品,有8.0%的患者将药物交给基层医生保管。医生趋利动机及病人对歧视的惧怕是造成医生保管药物比例低的原因。37.6%的病人表示在治疗过程中有县级结防机构医生到住处访视,39.8%的病人表示在治疗过程中有基层防保医生到住处访视。两级医生访视比例均较低,可能的原因是县乡两级医生人员不足及经费有限。
有15.9%的病人在治疗期间出现服药不依从现象。婚姻状况、化疗前是否接受宣传教育、免费政策对治疗激励性评价、督导管理人员与流动人口肺结核病人服药依从性相关。在婚病人服药依从率低于未婚病人；化疗前未接受宣传教育病人服药依从率低于接受宣传教育者；认为免费政策对治疗没有激励作用的病人服药依从率低于认为有激励作用者；由基层医生监督的患者服药依从率显著高于无人监督者。在已经终止治疗的病人中,治疗成功率为80.5%。知道结核病治疗疗程的病人治疗成功率高于不知道结核病治疗疗程的病人。
结论与政策建议
流动人口肺结核病人结核知识认知水平有待进一步提高,病人文化程度及家庭类型等是影响其认知水平的因素。确诊延迟与就诊延迟对延迟发现有近乎同等的影响,确诊延迟率略高于就诊延迟率。经济贫困是制约流动人口肺结核病患者求医行为的重要障碍因素之一；此外,工作时间、初始症状严重程度、卫生服务地理可及性等因素对延迟发现也有重要影响。流动人口肺结核病人求医行为过程复杂,需要多次就诊、经历多家医疗机构才能获得规则的抗结核治疗。在首诊时,卫生所(室)将病人诊断为疑似结核病的比例非常低；文化程度、家庭债务情况以及咯血／血痰症状与流动人口肺结核病人首诊机构选择有关。对流动人口开展常规结核病健康教育有利于结核病人及时发现。未接受宣传教育的病人服药依从性显著低于接受宣传教育的病人,知道结核病规则治疗疗程的病人完成治疗的比例高。有27.1%病人无任何督导管理,而是自服药。自服药病人治疗效果要低于实施督导管理的病人。基层医生在病人发现中扮演着非常重要的角色,但事实上并未能发挥其应有的作用。流动人口肺结核病人中,92.0%病人的药品由病人自己保管；两级医生访视比例均较低。流动人口肺结核病人中,有16.0%的病人在整个治疗过程中未能坚持规律服药。
为提高流动人口病人发现及治疗管理效果,提出如下建议：(1)加大流动人口结核病控制专项经费倾斜性投入力度,对投入资金加以监管,提高资金使用效率；(2)采取综合帮困措施,打破“贫困-结核病卫生服务利用低下-健康损伤-更贫困”的恶性循环,提高贫困流动人口结核病卫生服务可及性；(3)加强基层医生培训和激励,充分发挥基层医生在病人发现及治疗管理中的作用；(4)开展流动人口针对性健康教育,包括：加强流动人口流出地宣传教育,利用流动比较集中时期开展健康教育,开发简易健康教育资料,开展以雇主为中心的健康教育,化疗前100%健康教育；(5)加强流动人口肺结核病人自我管理指导。
创新性及不足
本研究的创新性主要体现在：
(1)目前国内外未见有对流动人口肺结核病人诊治全过程的系统性研究。本研究系统分析了流动人口从出现症状到求医到治疗全过程的现状及存在问题,并探索了相应障碍因素,为及早发现流动人口肺结核病人、改善其治疗管理效果提供了重要依据；
(2)本研究在求医行为障碍因素分析及路径描述的基础上,首次构建了流动人口肺结核病人求医行为决定因素模型及路径模型,为全面、系统了解流动人口肺结核病人求医行为过程提供了依据；
(3)本研究在描述流动人口肺结核病人延迟治疗时,为了解病人确诊后治疗的及时性,尝试使用了治疗延迟的指标,在描述病人治疗管理现状时,引入了流动人口肺结核病人化疗前接受专业人员健康教育率指标,并从需方角度探索了治疗管理相关影响因素。
本研究不足：
(1)本研究是以样本地区结核病防治机构为基础的研究,所有接受调查的病人均是结核病防治机构登记的病人。因此,本研究可能存在一定的选择偏性。
(2)本研究系回顾性研究,尽管在现场调查中,我们已采取了各种措施以控制质量,但回忆偏性在所难免,这可能会对研究结果造成一定的影响。
此外,部分病人在接受调查时,可能会因为理解偏颇或不愿意透露有关敏感信息,对病人收入及支出信息的真实性可能会产生影响。
Backgrounds
In the late 1980s, the increasing incidence of tuberculosis (TB) brought it back to be one of the foci of public health arousing global concerns. As one of the 22 countries of heavy disease burden of TB in the world, China ranks the second just following the India in terms of the number of TB patients.In recent years, with the implementation of DOTS strategy and more attention of government at all levels, epidemic situation of TB in China had been curbed to a certain extent. Even so, China is still facing a good deal of severe challenges, one of which is TB control among migrants in China. In 2009, the number of floating population in China had risen to 211 million. In next 30 years, China will form a "trisection" pattern of 500 million urban populations,500 million floating population and 500 million rural populations. Because of low income, poor working and living conditions, low education level, and weak awareness of health etc., TB epidemic situation among floating population is relatively serious. Rapid increase in the number of floating population is one of the most important reasons of TB epidemic rise. No fixed homes for most of floating population, high mobility, and difficulties in adhering to regular treatments and in treatment management result in increasing proportion of drug-resistant TB and risk of transmission, which brings out many obstacles to the regional TB control. TB control among migrants has become an urgent problem to solve in TB Control Programme of China.
Currently, TB control relies mainly on early detection of cases and completed treatment so as to cut transmission and reduce morbidity. Early detection requires a timely manner of identifying patients as suspicious TB cases and a rapid referral to TB dispensaries for diagnosis and treatment after their involvement in health system. Delays occurring in any part of health-seeking process would increase the probability of TB transmission and eventually result in high mortality. Therefore, the ability to detect TB patients among floating population is a key to the success of TB control. After diagnosis, treatment management of active tuberculosis patients and strengthened treatment management of smear-positive patients are necessary, so as to ensure patients complete treatment, otherwise, the success rate of treatment and cure rate would drop, number of drug-resistant TB cases would increase, which furthermore results in high risk of social transmission. Therefore, the effective management of patient treatment is another essential process in TB control among migrants.
However, after searching for existing literature, we found no systematic research on behaviors and pathways of migrants'health seeking and relevant factors, as well as special survey on migrant TB patients'treatment management. Therefore, we selected two important processes-behavior of health seeking and treatment management-mentioned above as research focuses.
Objectives
The general objective of this study is to explore current situation and problems of tuberculosis patients'health-seeking behavior and treatment management among migrants, in order to put forward some suggestions to improve TB case finding and treatment management effectiveness. The specific objectives include:identifying health-seeking behavior and its obstacles; establishing patients health-seeking behavior model based on identifying influencing factors of TB patients health-seeking behavior; evaluating on current situation of TB patients treatment management and relevant factors; identifying key problems in TB patients health-seeking behavior and treatment management among migrants; making strategic suggestion to promote TB case early detection and improve treatment management effectiveness.
Methods
Quantitative methods, qualitative methods and literature analysis were comprehensively used in this study so as to analyze the health-seeking behavior and treatment management and its problems to form a multi-angle research.
A total of 12 counties (districts) in 7 cities of Shandong province were selected as study sites according to the economic level and geography distribution and the number of smear-positive migrants TB cases registered during the past year. The smear-positive migrants TB cases registered in the 12 sampling counties (districts) TB dispensaries were recruited into the study, including 314 patients who were being treated and had completed normal treatment within 6 months.. Meanwhile, we carried out focus group discussion and in-depth discussion in 6 sites from the 12 sampling counties (districts). And directors, doctors of TB dispensaries, doctors of grass-roots medical institutions and migrants TB patients of the 6 sampling counties (districts) were interviewed as key informants to tell us their cognition on constraints of TB cases health-seeking behavior and problems existed in TB cases treatment management.
The data of this study mainly source from Shandong Statistics Yearbook, literature review, face-to-face interview of migrants TB cases and key informants discussion. The researchers and graduate students from School of public health of Shandong University, and some staff from Shandong Centre for TB Prevention and Control undertook the task of data collection. The data were entered using software EPI Data 6.04, then analyzed by using software SPSS 13.0. The methods of descriptive analysis, t-test, analysis of variance, Mann-Whitney U test, Kruskal-Wallis H test and multinomial logistic regression were applied in the research. The qualitative data were analyzed by descriptive analysis and case analysis.
Main results
TB core knowledge points among migrants TB cases were as follows:"what are the transmissions of tuberculosis", "what causes TB", "what are main symptoms of tuberculosis ", and "TB free treatment policy". TB cases awareness rate of all the four points were less than 75%. Over 90% of patients hold the view that TB could be curative. Education level and family type (from rural areas or urban areas) affected the level of migrants TB cases cognition.
The median of patient delay for migrants TB patients was 10 days, with an average of 18.84 days. Patients with a patient delay over 14 days accounted for 40.8%. The median of diagnosis delay was 8 days, with an average of 15.62 days. Patients with a diagnosis delay over 14 days accounted for 44.6%. The median of treatment delay was 1 days, with an average of 2.51 days. Patients with a treatment delay over 1 day accounted for 65.6%. TB patients with low household income, from poor/minimum living households, working over 5 days per week, without health insurance, taking over 30 minutes to the nearest township/street hospitals, with mild and moderate initial symptoms, with poor cognition on TB experienced longer patient delay. TB patients from younger group, working over 5 days per week, with a closer distance to local TB dispensaries, with mild initial symptoms, with first visit to clinics,under poor economic conditions experienced longer diagnosis delay. TB patients with low individual annual income, with accompany of relatives, with moderate and severe symptoms when diagnosed, with more severe symptoms when diagnosed compared with the initial symptoms, with the knowledge that TB cannot be cured and with little knowledge about TB free treatment policy experience longer treatment delay.
Nearly 70% of patients had cough at onset.48.73% of them selected health institutions of county level and above as their first visit health facilities, and 32.8% of them selected the grass-root clinics as their first visit health facilities. Education level, household debt status and initial symptom severity were factors affecting patients' selection of first visit health institutions. Patients with education level of junior high school and above preferred to go to health institutions of county level and above as their first visit health facilities, the patients with debt preferred to go to grass-root clinics as their first visit health facilities. The patients with initial symptoms of hemoptysis or bloody sputum preferred to go to county health institutions and above as their first visit health facilities.
Before the arrival at TB dispensaries (including the county TB dispensaries), TB patients'visit times ranged from 1 to 9, an average of 2.96 visits. Without considering repeated visits to the same health institutions, the average of health institutions visited was 2.44. The facilities involved in the process of migrant patients health-seeking behavior included health clinics, township (community) health centers, county (district) hospitals and above, and other hospitals or TB dispensaries, etc. TB patients'first visit health facilities had impact on the complexity of the process of health-seeking behavior. Patients'health-seeking pathways were associated with diagnosis delay. With the increase in the number of health facilities involved in the pathway, the median of diagnosis delay extended.
The number of patients who received TB-related health education prior to the chemotherapy accounted for 81.5%.58.3% of the patients experienced whole-process supervisory management,13.7% monitoring management during strengthening period of chemotherapy,1.0% whole-process management, and 27.1% self-medication. Patient supervisory management rate was 72.0%. Supply side factors were associated with patient supervisory management rate. Additionally, patients'working condition (including the type of occupation, working hours) was also an important factor that affected patients' supervisory management rate.
92.0% of patients kept anti-TB drugs by themselves,8.0% of patients gave their drugs to local primary physicians to keep. Primary physicians'pursuits of profits and patients' fear of discrimination caused the lowly drug-keeping percentage of primary physicians. 37.6% of the patients got visits to the residence from doctors in county TB dispensaries in the process of treatment.39.8% of the patients got visits to the residence from doctors of grass-root preventive doctors in the process of treatment. The low visit rate from county and township levels doctors may be due to lack of health personnel and limited funds.
15.9% of patients experienced non-compliance of using anti-TB drug in the process of treatment. Marital status, whether received TB-related health education prior to the chemotherapy or not, patients evaluation on the inventiveness of free treatment policies, treatment supervisor had significant relation to migrant patients compliance in using anti-TB drug. Married patients were easier to take drug regularly than single patients, patients who received TB-related health education prior to the chemotherapy had better compliance in drug-taking behavior than those who didn't, patients who thought the free treatment policy incentive had better compliance in drug-taking behavior than those who didn't, and patients who were supervised by clinic doctors were easier to take drug regularly than patients without supervisor. Among patients who had completed TB treatment, success rate of treatment was 80.5%. Patients who knew TB treatment regulations had higher success rate of treatment than those who didn't.
Conclusions and Recommendations
Migrant TB patients'cognition level on TB was rather low, and should be further enhanced. Patient educational level and family types were the factors that affected their cognition level. Diagnosis delay and patient delay had nearly same impact on delayed detection, and diagnosis delay rate was slightly higher than patient delay rate. Poverty was a crucial constraint for TB patients'access to health service among migrants, hi addition, working time, initial symptom severity and geographic accessibility to health service were factors influencing delayed detections. The process of health-seeking behavior among migrant TB patients was very sophisticated, requiring many visits(considering repeated visits to the same health institution) to medical institutions before accepting regular anti-TB treatment. In the first visit, the rate of diagnosing TB patients as suspected one by grass-root clinic doctors was low. Educational level, household debt status and initial symptom severity were factors affecting patients first visit selection of health institutions. To carry out TB-related health education prior to the chemotherapy was conducive to early detection of TB patients, high compliance in using anti-TB drug and high success rate of treatment.27.1% of patients took the medication without monitoring, which had negative effects on treatment outcome. Grass-root clinic doctors played a more important role in TB cases detection, but in fact failed to.92.0% of patients kept the anti-TB drug by themselves. The visit rate to patients'residence of doctors at county and township levels was rather low.16.0% failed to adhere to the regulation of using anti-TB drug in the whole process of treatment.
We put forward the following specific recommendations for the improvement of early TB case detection and treatment management effectiveness among migrants:(1) To increase the financial input of special funds for TB control among migrants, and strengthen the monitoring of funds to improve capital efficiency; (2) To adopt comprehensive measures helping the vulnerable poor to break the circle of "poverty-low utilization of TB health services-health damage-more poverty" so as to improve migrants'TB cases health services accessibility; (3) To strengthen training of primary care doctors and improve incentive mechanism, and give them more chances to play their full role in early case detection and treatment management; (4) To carry out targeted health education among floating population, including:strengthening propaganda and education on the floating population before their flowing out from their hometowns, carrying out health education during concentrated period of flowing, developing simple health education materials, carrying out the employer-centered health education, implementing 100% health education before chemotherapy; (5)To strengthen guidance on patients'self-management in the process of treatment.,
Innovations and Limitations
Innovations
(1) There lacks systematic researches concerning the overall process of diagnosis and treatment of TB patients among floating population at home and abroad. The study analyzes current situation and existing problems of the overall process from observable symptom to treatment among floating population systematically, and explores corresponding barriers, in order to provide essential suggestions to early detection and enhancing efficiency of treatment management;
(2) Based on the description of barriers of behaviors and path of seeking medical services, the study initially establishes the models of determinants and path of TB patients among floating population, in order to enhance the comprehensive and systematic understanding of the process of their seeking medical services;
(3) This study tries to employ index of delayed treatment so as to grasp the condition of timeliness of receiving treatment after diagnosis, introduces the rate of health education before regular treatment as an indicator to reflect the current situation of treatment management and explores relevant factors of it from the perspective of health service consumers.
Limitations
(1) There might be selective bias in the study due to the fact that our interviewees are all registered patients in prophylactic-therapeutic institutions.
(2) The study is retrospective. Although various measures were taken to control the survey's quality in the field, recall bias, bound to impose a certain effect on the study, is unavoidable.
In addition, when interviewed, patients might not tend to provide real sensitive information owing to privacy and biased understanding, in the sense that there is likely to be discrepancy between collected data and real condition in terms of income and expenditure.
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