农村卫生适宜技术推广综合评价研究
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摘要
研究目的
本研究旨在综合运用定性和定量研究方法,建立一套适合于经济发达地区农村卫生适宜技术推广实际应用,具有较高信度、效度和区分度的农村卫生适宜技术推广综合评估指标体系,并以浙江省为研究基地开展实证评估,以便提高农村卫生适宜技术推广规范化和科学化管理的程度,也为探讨我国卫生适宜技术推广长效机制提供参考和依据。
研究方法
本研究通过查阅和分析卫生评价、卫生技术评估和综合评价基本理论、方法以及国内外相关研究成果,确立研究框架和结构；采用文献分析法、专家讨论、专题小组访谈、Delphi专家咨询法建立指标体系,并采用层次分析法(AHP)法和百分权重法计算指标权重系数；利用现场调研、熵值法和Topsis法等方法对浙江省农村卫生适宜技术推广的技术需求、推广应用效果及满意度开展了研究；采用因子分析法、克朗巴赫α(Cronbach's alpha)系数、聚类分析和方差分析等数理统计方法进行指标体系的效度、信度和区分度的检验；运用加权累加综合评分法、加权秩和比法、综合指数法和Topsis法四种方法对浙江省农村卫生适宜技术推广进行了综合评价。
研究结果
本研究以适宜技术推广示范县为评价对象,对农村卫生适宜技术推广开展综合评价指标体系的研究。
1.综合评价指标体系的构建
(1)通过专家咨询、专题小组访谈等方法,从结构指标、过程指标和结果指标三个方面构建农村卫生适宜技术推广综合评价指标体系,同时将每个一类指标按照不同层次分为三级。
(2)评价指标体系共包括49个指标,其中3个一级指标,11个二级指标,35个三级指标。一级指标中,结构指标包括政府支持、组织管理2个二级指标以及6个三级指标；过程指标包括技术选择、技术培训、技术推广和推广长效机制4个二级指标以及13个三级指标；结果指标包括技术服务利用、疾病诊治效果、供方服务能力、患者受益程度和满意度5个二级指标以及16个三级指标。
(3)通过专家咨询、AHP法和百分权重法确定每级指标的权重。一级指标的权重值分别为：结构指标权重0.2680、过程指标权重0.3134、结果指标权重0.4186。二级指标的权重分别为：0.1397、0.1283、0.0819、0.0788、0.0783、0.0744、0.0851、0.900、0.0787、0.0851、0.0797。
2.农村卫生适宜技术推广评估分析调查
(1)通过现场调查基层卫生机构卫生技术人员,获得浙江省农村卫生适宜技术推广技术需求情况。
(2)通过现场问卷调查,对浙江省农村卫生适宜技术推广卫生技术人员培训效果开展评价；
(3)通过现场调查和访谈,采用熵值法、Topsis法对5个适宜技术推广示范县开展患者、卫生技术人员满意度评价。
3.实证分析
(1)对指标体系二级评价指标进行因子分析,验证评价指标体系的结构效度,因子分析结果显示,共提取3个公因子,其累计贡献率达到了96.080%。因子1受变量技术选择和技术培训等的影响,可看作是“过程指标”；因子2受变量组织管理和政府支持的影响,可看作“结构指标”；因子3受“满意度”和“疾病诊治”的影响,可看作“结果指标”。结果显示因子分析的结果与一级评价指标预设的指标相近,表明指标体系设计在总体上具有较好的结构效度,内在结构基本稳定。
(2)计算克朗巴赫α系数反映指标的内在信度。二级指标的克朗巴赫a标准值为0.831,三级指标的克朗巴赫α标准值为0.928,a值均大于0.7,指标的信度较高。
(3)聚类分析结果显示,5个评价地区分成好、中、差三类较为合理,方差分析的结果也表明,三组之间的差异在统计学上有显著意义(P<0.05),指标体系具有较好的区分度。
(4)运用加权累加综合评分法、加权秩和比法、综合指数法和Topsis法四种评价方法,对农村卫生适宜技术推广进行综合评价,验证评价指标的稳定性和指标体系的可操作性。综合评价的结果显示各种评价方法结果趋同,说明了所筛选出的评价指标能用于农村卫生适宜技术推广评价。
结论
基于上述研究结果,本研究得出以下结论与相关建议：
1.本研究采用Delphi专家咨询和专题小组讨论法等对评价指标进行筛选,结果具有一定的合理性和可靠性,评价指标体系结构合理,评价内容完整。
2.指标体系构建在专家评判的基础上,采用AHP和百分权重法计算指标权重,确保了指标权重的科学性和准确性。
3.实证分析表明,指标体系具有较好的信度、效度和区分度,结果可信。
4.不同综合评价方法的结果具有一致性,说明评价指标体系有较好的稳定性和可操作性,也说明评价指标体系能够用于对农村卫生适宜技术推广效果的评价。
5.综合评价结果表明,卫生适宜技术推广的推广模式影响推广的效果。
6.根据卫生适宜技术的特点,充分发挥政府的作用,形成适宜技术推广长效机制,保证技术推广可持续发展。
本次研究的创新点
本研究创新点体现在以下几方面：
1.本研究在卫生技术评价、卫生服务评价和综合评价理论基础上,基于多那比迪安(Donabedian)提出的三维内涵的管理评价理论：结构、过程、结果(structure-process-outcome)评价模式,首次建立了农村卫生适宜技术推广结构、过程及结果三位一体的的结构模型。
2.第一次采用科学的方法较为系统、全面地验证了农村卫生适宜技术推广综合评价指标体系的信度、效度和区分度,弥补了当前该领域研究的不足,使指标体系的建立更加具有科学性和合理性,同时为以后的相关研究提供了一些可借鉴的方法学基础。
3.本课题研究现有卫生适宜技术推广的综合效果,建立评价模型并开展实证评估,将为我国开展卫生适宜技术推广提供借示范鉴经验,对建立农村卫生适宜技术推广长效机制以及卫生资源的合理优化配置具有重要的理论和应用价值。
Research Purposes
This research is to use qualitative and quantitative methods to develop an comprehensive and scientific evaluation indicator system with high validity, reliability and differentiation for evaluating transferring and application of Appropriate Health Care Technologies in Rural of developed areas of China, which is suitable for the current development situation of transferring of Rural Appropriate Health Care Technology and easy to carry out and spread, taking Zhejiang province as research base in empirical evaluation, and thereby to improve the scientific, standardized and normalized administration level of transferring and using appropriate technology for health, also provide reference and basis for discussing of promotion application mechanism transferring of Rural Appropriate Health Care Technology.
Research Methods
This study establish research framework and structure by analyzing and referring the basic theory and method of health technology assessment, health evaluation and comprehensive evaluation, and related research achievements at home and abroad; in this study, literature review and analysis, personal interview, group discussion, field investigation and delphi method were used to develop the indicator system, Analytic Hierarchy Process(AHP) and Percent weighting method was used to calculate the weight of the indicators; Factor analysis, Cronbach's alpha coefficient,Cluster analysis and ANOVA analysis were adopted to test the validity, reliability and differentiation of indicator system; Comprehensive indicator method, Topsis method, Accumulative synthtical grading evaluation, Rank Sum Ratio(RSR) method were applied to evaluate transferring of the rural appropriate health technology in 5 demonstration counties of Zhejiang province.
Research Results
1. An evaluation indicator system for transferring of the rural appropriate health technology is to be developed in three aspects of the structure, the process and the outcome indicator, by means of experts consultation, key informant interviews, etc. Meanwhile, each category of indicator is to be classified into 3 classes according to its levels.
2. The evaluation index system was established including 49 indexes:3 class 1 indicators,11 class 2 indicators and 35 class 3 indicators.
3. The weighting of each class of indicators is determined by experts consultation, Analytic Hierarchy Process(AHP) and Percent weighting method. The weighting of class 1 indicators is 0.2680,0.3134 and 0.4186 respectively. The weighting of class 2 indicators is 0.1397,0.1283,0.0819,0.0788,0.0783,0.0744,0.0851,0.900,0.0787,0.0851 and 0.0797 respectively.
4.Factor analysis to each classes of evaluation indicators is made to test the structure validity of the indicator system, The factor analysis of the second class indicators showed that totally three common factors were extracted,the accumulative variance reached 96.080%.The common factor 1(F1) is mainly influenced by variable "appropriate health technology select" and "health technology teaching", etc., it could be named as process indicator, F2 influenced by variable "The government support" and "organization and management", etc., it could be named as structure indicator; F3 is mainly influenced by variable "degree of satisfaction" and "diseases diagnosis and treatment", etc., and it could be named as outcome indicator. The results of factor analysis are accordant with the expected results and it shows the indicator system has good validity.
5.The internal reliability of indicators is reflected by calculation of Cronbach's coefficient a. The standard value of Cronbach's coefficient a for class 2 indicators is 0.830; the standard value of Cronbach's coefficient a for class 3 indicators is 0.928.The value of a for class 2 and class 3 indicators are all larger than 0.7, indicating higher reliability of indicators.
6. According to the cluster analysis, it is appropriate to divide the 5 demonstration counties into 3 groups, and the ANOVA analysis showed that the differences among the three groups are statistical significant (P<0.05), the differentiation of the indicators is good.
7. The results of comprehensive evaluation showing relevant convergence of different evaluation methods, indicate that these evaluation indicators can be used for the evaluation of the appropriate health technologies transferring in rural and the evaluation indicator system is relatively stable.
Conclusions
l.The results are relatively reliable as evaluation indices are screened with Delphi expert consultation and group discussion method, etc., the evaluation system has relatively reasonable structure as well as integral and complete contents in evaluation.
2. On the basis of judgment by experts, the weighting of indicators is calculated with Analytic Hierarchy Process(AHP) and Percent weighting method to ensure scientific, accurate and reasonable calculation results.
3. The evaluation system has good validity, reliability and differentiation, it is suitable for evaluating the appropriate health technologies transferring in rural.
4. The results of different comprehensive evaluation methods shows the evaluation indicator system has good stability and operability, and also indicates that the evaluation indicator system developed can be used for evaluation, of the appropriate health technologies transferring in rural.
5. The results of comprehensive evaluation show that the achievement of the appropriate health technologies transferring in rural is effected by the extension model of it.
6. According to the characteristics of appropriate health technology, give full play to the government's role, form long-term effect mechanism for promotion the appropriate health technologies transferring in rural.
本研究旨在综合运用定性和定量研究方法,建立一套适合于经济发达地区农村卫生适宜技术推广实际应用,具有较高信度、效度和区分度的农村卫生适宜技术推广综合评估指标体系,并以浙江省为研究基地开展实证评估,以便提高农村卫生适宜技术推广规范化和科学化管理的程度,也为探讨我国卫生适宜技术推广长效机制提供参考和依据。
研究方法
本研究通过查阅和分析卫生评价、卫生技术评估和综合评价基本理论、方法以及国内外相关研究成果,确立研究框架和结构；采用文献分析法、专家讨论、专题小组访谈、Delphi专家咨询法建立指标体系,并采用层次分析法(AHP)法和百分权重法计算指标权重系数；利用现场调研、熵值法和Topsis法等方法对浙江省农村卫生适宜技术推广的技术需求、推广应用效果及满意度开展了研究；采用因子分析法、克朗巴赫α(Cronbach's alpha)系数、聚类分析和方差分析等数理统计方法进行指标体系的效度、信度和区分度的检验；运用加权累加综合评分法、加权秩和比法、综合指数法和Topsis法四种方法对浙江省农村卫生适宜技术推广进行了综合评价。
研究结果
本研究以适宜技术推广示范县为评价对象,对农村卫生适宜技术推广开展综合评价指标体系的研究。
1.综合评价指标体系的构建
(1)通过专家咨询、专题小组访谈等方法,从结构指标、过程指标和结果指标三个方面构建农村卫生适宜技术推广综合评价指标体系,同时将每个一类指标按照不同层次分为三级。
(2)评价指标体系共包括49个指标,其中3个一级指标,11个二级指标,35个三级指标。一级指标中,结构指标包括政府支持、组织管理2个二级指标以及6个三级指标；过程指标包括技术选择、技术培训、技术推广和推广长效机制4个二级指标以及13个三级指标；结果指标包括技术服务利用、疾病诊治效果、供方服务能力、患者受益程度和满意度5个二级指标以及16个三级指标。
(3)通过专家咨询、AHP法和百分权重法确定每级指标的权重。一级指标的权重值分别为：结构指标权重0.2680、过程指标权重0.3134、结果指标权重0.4186。二级指标的权重分别为：0.1397、0.1283、0.0819、0.0788、0.0783、0.0744、0.0851、0.900、0.0787、0.0851、0.0797。
2.农村卫生适宜技术推广评估分析调查
(1)通过现场调查基层卫生机构卫生技术人员,获得浙江省农村卫生适宜技术推广技术需求情况。
(2)通过现场问卷调查,对浙江省农村卫生适宜技术推广卫生技术人员培训效果开展评价；
(3)通过现场调查和访谈,采用熵值法、Topsis法对5个适宜技术推广示范县开展患者、卫生技术人员满意度评价。
3.实证分析
(1)对指标体系二级评价指标进行因子分析,验证评价指标体系的结构效度,因子分析结果显示,共提取3个公因子,其累计贡献率达到了96.080%。因子1受变量技术选择和技术培训等的影响,可看作是“过程指标”；因子2受变量组织管理和政府支持的影响,可看作“结构指标”；因子3受“满意度”和“疾病诊治”的影响,可看作“结果指标”。结果显示因子分析的结果与一级评价指标预设的指标相近,表明指标体系设计在总体上具有较好的结构效度,内在结构基本稳定。
(2)计算克朗巴赫α系数反映指标的内在信度。二级指标的克朗巴赫a标准值为0.831,三级指标的克朗巴赫α标准值为0.928,a值均大于0.7,指标的信度较高。
(3)聚类分析结果显示,5个评价地区分成好、中、差三类较为合理,方差分析的结果也表明,三组之间的差异在统计学上有显著意义(P<0.05),指标体系具有较好的区分度。
(4)运用加权累加综合评分法、加权秩和比法、综合指数法和Topsis法四种评价方法,对农村卫生适宜技术推广进行综合评价,验证评价指标的稳定性和指标体系的可操作性。综合评价的结果显示各种评价方法结果趋同,说明了所筛选出的评价指标能用于农村卫生适宜技术推广评价。
结论
基于上述研究结果,本研究得出以下结论与相关建议：
1.本研究采用Delphi专家咨询和专题小组讨论法等对评价指标进行筛选,结果具有一定的合理性和可靠性,评价指标体系结构合理,评价内容完整。
2.指标体系构建在专家评判的基础上,采用AHP和百分权重法计算指标权重,确保了指标权重的科学性和准确性。
3.实证分析表明,指标体系具有较好的信度、效度和区分度,结果可信。
4.不同综合评价方法的结果具有一致性,说明评价指标体系有较好的稳定性和可操作性,也说明评价指标体系能够用于对农村卫生适宜技术推广效果的评价。
5.综合评价结果表明,卫生适宜技术推广的推广模式影响推广的效果。
6.根据卫生适宜技术的特点,充分发挥政府的作用,形成适宜技术推广长效机制,保证技术推广可持续发展。
本次研究的创新点
本研究创新点体现在以下几方面：
1.本研究在卫生技术评价、卫生服务评价和综合评价理论基础上,基于多那比迪安(Donabedian)提出的三维内涵的管理评价理论：结构、过程、结果(structure-process-outcome)评价模式,首次建立了农村卫生适宜技术推广结构、过程及结果三位一体的的结构模型。
2.第一次采用科学的方法较为系统、全面地验证了农村卫生适宜技术推广综合评价指标体系的信度、效度和区分度,弥补了当前该领域研究的不足,使指标体系的建立更加具有科学性和合理性,同时为以后的相关研究提供了一些可借鉴的方法学基础。
3.本课题研究现有卫生适宜技术推广的综合效果,建立评价模型并开展实证评估,将为我国开展卫生适宜技术推广提供借示范鉴经验,对建立农村卫生适宜技术推广长效机制以及卫生资源的合理优化配置具有重要的理论和应用价值。
Research Purposes
This research is to use qualitative and quantitative methods to develop an comprehensive and scientific evaluation indicator system with high validity, reliability and differentiation for evaluating transferring and application of Appropriate Health Care Technologies in Rural of developed areas of China, which is suitable for the current development situation of transferring of Rural Appropriate Health Care Technology and easy to carry out and spread, taking Zhejiang province as research base in empirical evaluation, and thereby to improve the scientific, standardized and normalized administration level of transferring and using appropriate technology for health, also provide reference and basis for discussing of promotion application mechanism transferring of Rural Appropriate Health Care Technology.
Research Methods
This study establish research framework and structure by analyzing and referring the basic theory and method of health technology assessment, health evaluation and comprehensive evaluation, and related research achievements at home and abroad; in this study, literature review and analysis, personal interview, group discussion, field investigation and delphi method were used to develop the indicator system, Analytic Hierarchy Process(AHP) and Percent weighting method was used to calculate the weight of the indicators; Factor analysis, Cronbach's alpha coefficient,Cluster analysis and ANOVA analysis were adopted to test the validity, reliability and differentiation of indicator system; Comprehensive indicator method, Topsis method, Accumulative synthtical grading evaluation, Rank Sum Ratio(RSR) method were applied to evaluate transferring of the rural appropriate health technology in 5 demonstration counties of Zhejiang province.
Research Results
1. An evaluation indicator system for transferring of the rural appropriate health technology is to be developed in three aspects of the structure, the process and the outcome indicator, by means of experts consultation, key informant interviews, etc. Meanwhile, each category of indicator is to be classified into 3 classes according to its levels.
2. The evaluation index system was established including 49 indexes:3 class 1 indicators,11 class 2 indicators and 35 class 3 indicators.
3. The weighting of each class of indicators is determined by experts consultation, Analytic Hierarchy Process(AHP) and Percent weighting method. The weighting of class 1 indicators is 0.2680,0.3134 and 0.4186 respectively. The weighting of class 2 indicators is 0.1397,0.1283,0.0819,0.0788,0.0783,0.0744,0.0851,0.900,0.0787,0.0851 and 0.0797 respectively.
4.Factor analysis to each classes of evaluation indicators is made to test the structure validity of the indicator system, The factor analysis of the second class indicators showed that totally three common factors were extracted,the accumulative variance reached 96.080%.The common factor 1(F1) is mainly influenced by variable "appropriate health technology select" and "health technology teaching", etc., it could be named as process indicator, F2 influenced by variable "The government support" and "organization and management", etc., it could be named as structure indicator; F3 is mainly influenced by variable "degree of satisfaction" and "diseases diagnosis and treatment", etc., and it could be named as outcome indicator. The results of factor analysis are accordant with the expected results and it shows the indicator system has good validity.
5.The internal reliability of indicators is reflected by calculation of Cronbach's coefficient a. The standard value of Cronbach's coefficient a for class 2 indicators is 0.830; the standard value of Cronbach's coefficient a for class 3 indicators is 0.928.The value of a for class 2 and class 3 indicators are all larger than 0.7, indicating higher reliability of indicators.
6. According to the cluster analysis, it is appropriate to divide the 5 demonstration counties into 3 groups, and the ANOVA analysis showed that the differences among the three groups are statistical significant (P<0.05), the differentiation of the indicators is good.
7. The results of comprehensive evaluation showing relevant convergence of different evaluation methods, indicate that these evaluation indicators can be used for the evaluation of the appropriate health technologies transferring in rural and the evaluation indicator system is relatively stable.
Conclusions
l.The results are relatively reliable as evaluation indices are screened with Delphi expert consultation and group discussion method, etc., the evaluation system has relatively reasonable structure as well as integral and complete contents in evaluation.
2. On the basis of judgment by experts, the weighting of indicators is calculated with Analytic Hierarchy Process(AHP) and Percent weighting method to ensure scientific, accurate and reasonable calculation results.
3. The evaluation system has good validity, reliability and differentiation, it is suitable for evaluating the appropriate health technologies transferring in rural.
4. The results of different comprehensive evaluation methods shows the evaluation indicator system has good stability and operability, and also indicates that the evaluation indicator system developed can be used for evaluation, of the appropriate health technologies transferring in rural.
5. The results of comprehensive evaluation show that the achievement of the appropriate health technologies transferring in rural is effected by the extension model of it.
6. According to the characteristics of appropriate health technology, give full play to the government's role, form long-term effect mechanism for promotion the appropriate health technologies transferring in rural.
引文
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