基于结构方程模型的艾滋病卫生服务利用影响因素及策略干预研究

Human health and social development are facing a serious threat from HIV/AIDS. It was reported by World Health Organization in 2013 that measures integrating prevention into treatment, especially Highly Active Antiretroviral Therapy (HAART) for early stage, is going to bring a remarkable effect on HIV prevention and treatment. However, whether HIV-related health service, including HAART, is utilized very well plays a key role in bringing about these supposed effects. However, the undesirable utilization of HIV-related health services in China is impeding this impact recently. Though the theoretical model based on foreign researches on factors associated with utilization is more mature compared with domestic researches, this based on other countries mightn't suit to China's national conditions. The developed mathematical model can't reveal the potential variables in term of social and psychological, estimate the interaction among these variables and "Multi-factor and multi-result" relationship. Fewer researches focus on policy intervention and evaluation through prospective pilot study. During carry outing the comprehensive research, a variety of methods is going to be used to build theoretical and mathematical models suiting to Chinese actual situation, including Scientific Program of Policy Making, Andersen Model, Structural Equation Model, Cross-sectional Survey, Intervention-control Study, Delphi Method and In-depth Interviews, etc. The current situation and factors associated with HIV-related health service utilization will be discovered. Strategies and relativemeasures shall be developed through alternative formulation, feasibility study, intervention trial, evaluation and optimization to improve utilization and achieve the effects declared by WHO.

艾滋病严重威胁人类健康和社会发展。2013年WHO发布，有效防治结合措施尤其高效抗逆转录治疗（HAART）规范早期启动，治疗效果显著且能大幅降低HIV传播。然而，包括HAART在内的艾滋病相关卫生服务利用的好坏成为这一效果实现的关键。不容乐观的我国利用现状严重影响这一效果达成。 国外理论模型已较成熟，但国情差异下能否适合我国不得而知；数学模型尚无法揭示涉及社会、心理的潜在变量，无法估计"多因-多果"关系及多因素间的相互作用；缺乏基于前瞻性试点的策略干预与评价研究。为弥补国内研究的缺憾，研究集成政策制定科学程序、Andersen模型、结构方程、横断面调查、干预-对照研究、专家咨询及深入访谈等方法，构建适合我国国情的理论与数学模型，明确我国艾滋病卫生服务利用现状及影响因素；通过政策研制、可行性评价、干预试点、评价，与优化，构建并最终推荐改进策略及措施。为切实保障卫生服务利用及其效果提供科学依据

随着艾滋病病毒感染者/艾滋病病人（PLWHA）期望寿命得到显著提升，其卫生服务利用的重心也从早期对症治疗转移为门诊、住院等一般慢性病人群的医疗需求。同时艾滋病相关卫生服务的利用中严格遵从医疗方案会使得治疗效果更加显著，因此患者能否维持理想的治疗依从性是有效利用艾滋病卫生服务的关键。. 本研究建立了上海市、河南省周口市、云南省大理州、浙江省的1734名艾滋病人群现场，关注点包括：（1）运用文献归纳分析、专家咨询、回顾性现况调查方法，明确我国艾滋病相关卫生服务利用现状及其有效利用的依从性标准界定。（2）确定Cha et al.’s model为PLWHA依从性研究的理论基础，利用结构方程模型构建适合中国背景的依从性及其社会心理影响因素模型。（3）保障我国艾滋病相关卫生服务利用的策略构建、评价与优化研究。（4）同时利用浙江省16265名PLWHA的检验数据库开展回顾性队列研究，分析时间趋势及其他因素对病毒学失败的影响。. 云南大理州461例PLWHA的调查表明，PLWHA中两周就诊率为22.6%，远高于一般人群的7.8%。PLWHA的灾难性卫生支出发生率为25.2%，而同地区家庭灾难性卫生支出发生率为11.19%。97.2％的浙江省调查对象认为在过去一个月内服用的实际剂量比例超过处方规定的95％，476例（94.44％）报告他们在过去一个月内在±2小时内服用了规定剂量药物。在数学模型构建中：较高的自我效能与高依从性相关；更高的社会支持与低抑郁有关；较高抑郁与自我效能降低之间也有明显关联；耻辱与抑郁呈现正相关，与社会支持呈负相关。. PLWHA的家庭灾难性卫生支出发生率要高于全国平均水平，一旦发生灾难性卫生支出，会给家庭经济带来沉重打击；同时医保报销后患者自身的最大支付能力仍无法弥补其所面对的高额费用负担，因病致贫的压力仍然巨大。提高患者的社会支持与自我效能是缓解羞耻感的重要手段，可通过有效促进感染者之间的互相支持，增进感染者和志愿者之间良好的人际关系。