农村妇女“两癌”筛查服务的利用与提供:TPB理论框架下基于妇女和基层卫生人员行为的研究

Recently, the incidence of both breast cancer and cervical cancer increased year by year in China, which poses a serious threat to the health status of Chinese women. Research indicates that breast cancer and cervical cancer screening services can significantly improve the early diagnostic rate and reduce mortality rate. The screening program which is implemented in rural areas has been regarded as one critical public health policy in China. Nevertheless, due to some impact factors, service utilization and service delivery of breast and cervical cancer screening program are relatively low, which has serious negative impact on the effects of screening services. Specifically, the willingness and behavior about the screening services of rural women (the demander) and the rural primary health care providers (the supplier) are very low. Accordingly, applying the theory of planned behavior (TPB) as the theoretical framework, this project will construct theoretical models on the behaviors of demanders and suppliers and make empirical tests. By aiming to explore the subjective and objective factors and internal mechanism，the project will explore the key factors that impact the demander and suppliers’ willingness and behavior about the screening services and help build a foundation for future interventions. Based on the key factors and internal mechanism, the project strives to put forward countermeasures that can develop positive factors and eliminate obstacles factors. In order to elevate the level of service utilization and service delivery of breast and cervical cancer screening services, the project will put forward policy suggestions to the government. Meanwhile, the results will be of value for public health services system.

近年来，我国“两癌”即乳腺癌和宫颈癌癌的发病率逐年递增，对妇女人群健康构成了较大威胁，研究表明，癌症筛查可以有效提高“两癌”的早期诊断率，降低死亡率，我国政府将农村“两癌”筛查作为重要的公共卫生服务项目之一。但是，受多种因素影响，当前农村适龄妇女（需方）参与“两癌”筛查服务和农村基层医疗卫生机构人员（供方）提供“两癌”筛查服务的意愿与行为均处于较低水平，严重影响了筛查服务的效果。本项目围绕上述问题展开理论研究与实证探索,基于计划行为(TPB)理论构建清晰的服务利用与服务提供行为模型，开展实证检验，探讨影响供需双方“两癌”筛查服务利用行为与服务提供行为的主、客观因素及其内在作用机制，识别关键因素，并提出调动积极因素、消除阻碍因素的对策，为进一步干预奠定基础。研究结果可为政府部门制定提升农村妇女“两癌”筛查服务利用与供给水平的政策提供理论参考和决策依据,并对完善公共卫生服务体系具有积极意义。

癌症筛查可以有效提高宫颈癌和乳腺癌的早期诊断率，降低死亡率。本研究基于计划行为理论(TPB)构建了农村“两癌”筛查服务利用与服务提供行为模型，探讨影响供需双方行为的主、客观因素及其内在作用机制，识别关键因素。围绕上述关键问题，本研究在江苏省5个设区市20个调查点开展现场调查，重要结果有：（1）面向3042位农村妇女的宫颈癌筛查问卷调查表明，行为意向比较积极的占比69.7%，从未参加过宫颈癌筛查的人数占比40.7%；主观规范（=0.345，p＜0.001）是参与宫颈癌筛查行为意向的重要影响因素。（2）对3011位农村妇女进行乳腺癌筛查相关调查，行为意愿比较积极的占比70.1%，68.2%的农村妇女从未、几乎、很少接受过乳腺癌筛查。主观规范是最强的预测因子，态度、主观规范、知觉行为控制、知识和过去的筛查行为与乳腺癌筛查行为意向呈正相关；（3）对1120名基层医务人员提供宫颈癌筛查行为意愿影响因素进行实证调查，79.2%的基层医务人员对提供宫颈癌筛查持积极态度。对宫颈癌筛查的知识水平良好，总知识水平的平均分是3.85±1.11（得分区间为0-5），态度与提供筛查服务行为意愿相关（β=0.264，p<0.001），主观规范与行为意向（β=0.311，p<0.001），态度（β=0.634，p<0.001）和知觉行为规范（β=0.305，p<0.001）显著相关；（4）1101名基层医务人员提供乳腺癌筛查实证调查结果表明，75.4%基层医务人员具有较强的提供乳腺癌筛查服务的意愿，但过去提供筛查行为较低。对基层医务人员提供乳腺癌筛查行为意向影响最大的潜变量是主观规范（β＝0.352, p＜0.001）。基于此，提出策略建议有：“两癌”宣教的对象不能局限于适龄农村妇女，而是应通过社会和家庭使筛查社会认知不断提高；精简宣教内容，制定个性化指导和宣教；加大政府支持，提高基层医疗服务水平；加强基层卫生人员的激励，建立合理绩效考核制度。本研究到目前为止已发表（录用）5篇中文论文、3篇国际英文SCI期刊论文；相关研究结果在3次国内外学术会议上报告；培养1名博士研究生、2名硕士研究生和1名本科生。