楊文珍，王亞?wèn)|*，王貴齊，徐俊杰，劉 茉

·專題研究·

·論著·

基于社區(qū)參與式研究方法的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式效果評(píng)價(jià)

楊文珍1，王亞?wèn)|1*，王貴齊2，徐俊杰3，劉 茉1

目的 評(píng)價(jià)基于社區(qū)參與式研究方法(CBPR)的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式的效果。方法 2014年3—8月，采用目的抽樣法從北京市韓村河鎮(zhèn)的27個(gè)行政村中選取2個(gè)村(五侯村、孤山口村)作為社區(qū)干預(yù)試驗(yàn)現(xiàn)場(chǎng)，采用簡(jiǎn)單隨機(jī)抽樣法將其分為干預(yù)組(五侯村)和對(duì)照組(孤山口村)。五侯村、孤山口村分別有911、936例村民符合結(jié)直腸癌篩查要求，將其作為篩查的目標(biāo)人群，采用高危因素問(wèn)卷和便隱血試驗(yàn)(FOBT)(2次)進(jìn)行初篩，對(duì)高危人群進(jìn)行腸鏡檢查。干預(yù)組采用基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式進(jìn)行干預(yù)，對(duì)照組采用一般性組織動(dòng)員模式進(jìn)行干預(yù)。2014年3月，選取五侯村、孤山口村符合納入標(biāo)準(zhǔn)的村民745例為調(diào)查對(duì)象，采用自制調(diào)查問(wèn)卷進(jìn)行干預(yù)前的基線調(diào)查。2014年8月，再次選取五侯村、孤山口村符合納入標(biāo)準(zhǔn)的村民740例為調(diào)查對(duì)象，采用自制調(diào)查問(wèn)卷進(jìn)行干預(yù)后的終末調(diào)查。記錄兩組一般資料，結(jié)直腸癌篩查消息知曉率、宣傳折頁(yè)獲得率、宣傳海報(bào)關(guān)注率、知識(shí)得分、態(tài)度得分，初篩參與率，腸鏡參與率。結(jié)果 基線調(diào)查共發(fā)放調(diào)查問(wèn)卷745份(對(duì)照組363份、干預(yù)組382份)，回收有效問(wèn)卷707份(對(duì)照組343份、干預(yù)組364份)，有效回收率為94.9%。終末調(diào)查共發(fā)放調(diào)查問(wèn)卷740份(對(duì)照組359份、干預(yù)組381份)，回收有效問(wèn)卷696份(對(duì)照組330份、干預(yù)組366份)，有效回收率為94.1%。干預(yù)組結(jié)直腸癌篩查消息知曉率、宣傳折頁(yè)獲得率、宣傳海報(bào)關(guān)注率均高于對(duì)照組(P<0.05)。兩組干預(yù)后結(jié)直腸癌篩查知識(shí)得分、態(tài)度得分均高于本組干預(yù)前(P<0.05)；干預(yù)組干預(yù)前后結(jié)直腸癌篩查知識(shí)得分均高于對(duì)照組(P<0.05)；干預(yù)組干預(yù)前結(jié)直腸癌篩查態(tài)度得分與對(duì)照組比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；干預(yù)組干預(yù)后結(jié)直腸癌篩查態(tài)度得分高于對(duì)照組(P<0.05)。獨(dú)立混合橫截面數(shù)據(jù)的雙重差分模型分析結(jié)果顯示：兩組干預(yù)前后結(jié)直腸癌篩查知識(shí)得分差值比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；干預(yù)組干預(yù)前后結(jié)直腸癌篩查態(tài)度得分差值大于對(duì)照組(P<0.05)。二分類非條件Logistic回歸分析結(jié)果顯示：干預(yù)組較對(duì)照組初篩參與率高23.8%(P<0.05)；兩組腸鏡參與率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式較大程度提高了村民結(jié)直腸癌篩查的消息知曉情況和初篩參與行為；但由于村民文化程度低等原因，其對(duì)村民的結(jié)直腸癌篩查知識(shí)掌握情況、態(tài)度影響較小。

結(jié)直腸腫瘤；農(nóng)村人口；篩查；干預(yù)效果評(píng)價(jià)；組織動(dòng)員

楊文珍,王亞?wèn)|,王貴齊,等.基于社區(qū)參與式研究方法的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式效果評(píng)價(jià)[J].中國(guó)全科醫(yī)學(xué)，2017，20(6)：651-656.[www.chinagp.net]

YANG W Z,WANG Y D,WANG G Q,et al.Effectiveness evaluation of mobilization model of colorectal cancer screening in rural area on the basis of community-based participatory research method[J].Chinese General Practice，2017，20(6)：651-656.

結(jié)直腸癌是我國(guó)第4位高發(fā)惡性腫瘤，2012年我國(guó)結(jié)直腸癌發(fā)病率為24.47/10萬(wàn)[1]，給人們?cè)斐蓢?yán)重的經(jīng)濟(jì)負(fù)擔(dān)和巨大的生命損失，而結(jié)直腸癌篩查是降低結(jié)直腸癌發(fā)病率和病死率的有效手段[2-5]。盡管篩查能通過(guò)發(fā)現(xiàn)癌前病變和早期癌降低病死率，但各國(guó)在開(kāi)展篩查工作時(shí)均面臨人群參與率低的問(wèn)題[6-8]。我國(guó)結(jié)直腸癌篩查工作開(kāi)展較晚，參與率處于相對(duì)較低水平[9-11]。目前，關(guān)于我國(guó)農(nóng)村結(jié)直腸癌篩查參與率的研究很少。為提高農(nóng)村人群篩查參與率，本研究組前期設(shè)計(jì)了基于社區(qū)參與式研究方法(CBPR)的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式并初步分析其效果[12]，本研究擬進(jìn)一步評(píng)價(jià)其效果，從而為農(nóng)村結(jié)直腸癌篩查工作的開(kāi)展提供依據(jù)。

1 資料與方法

1.1 研究現(xiàn)場(chǎng) 2014年3—8月，采用目的抽樣法從北京市韓村河鎮(zhèn)的27個(gè)行政村中選取2個(gè)村(五侯村、孤山口村)作為社區(qū)干預(yù)試驗(yàn)現(xiàn)場(chǎng)，進(jìn)行免費(fèi)結(jié)直腸癌篩查，采用簡(jiǎn)單隨機(jī)抽樣法將其分為干預(yù)組(五侯村)和對(duì)照組(孤山口村)。納入標(biāo)準(zhǔn)：(1)人口結(jié)構(gòu)特征、基本經(jīng)濟(jì)情況較為相近；(2)地理位置相對(duì)隔開(kāi)，從而減少“組間沾染”；(3)屬于該鎮(zhèn)人口基數(shù)較大的村。五侯村、孤山口村分別有911、936例村民符合篩查要求〔有當(dāng)?shù)貞艏?，常?居住時(shí)間>0.5年)，40～74周歲〕，將其作為篩查的目標(biāo)人群，采用高危因素問(wèn)卷[13]和便隱血試驗(yàn)(FOBT)(2次)進(jìn)行初篩，高危因素問(wèn)卷或2次FOBT任一陽(yáng)性則定義為高危人群，對(duì)高危人群進(jìn)行腸鏡檢查。

1.2 干預(yù)方法 干預(yù)組采用基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式進(jìn)行干預(yù)，干預(yù)措施主要包括：(1)請(qǐng)村委會(huì)協(xié)助招募遴選社區(qū)領(lǐng)袖，進(jìn)而組建以社區(qū)領(lǐng)袖為核心的社區(qū)篩查小組；(2)基線調(diào)查了解村民需求，從而優(yōu)化篩查時(shí)間、地點(diǎn)，改進(jìn)篩查流程；(3)利用村委會(huì)廣播系統(tǒng)進(jìn)行通知宣傳并在篩查現(xiàn)場(chǎng)張貼宣傳海報(bào)、懸掛宣傳橫幅、發(fā)放宣傳折頁(yè)；(4)社區(qū)領(lǐng)袖率先進(jìn)行篩查，樹(shù)立篩查模范；(5)社區(qū)領(lǐng)袖協(xié)助宣傳教育，各自在所屬區(qū)域進(jìn)行入戶口頭告知，發(fā)放宣傳折頁(yè)；(6)社區(qū)領(lǐng)袖與社區(qū)醫(yī)務(wù)人員一對(duì)一搭檔入戶進(jìn)行個(gè)性化勸導(dǎo)。對(duì)照組采用一般性組織動(dòng)員模式進(jìn)行干預(yù)，干預(yù)措施主要包括：(1)利用村委會(huì)的廣播系統(tǒng)，篩查期間早、中、晚各進(jìn)行5次廣播通知，告知村民免費(fèi)篩查活動(dòng)的時(shí)間、地點(diǎn)和參加篩查的好處等；(2)由項(xiàng)目組成員在篩查現(xiàn)場(chǎng)張貼宣傳海報(bào)，懸掛宣傳橫幅，發(fā)放宣傳折頁(yè)。

1.3 問(wèn)卷調(diào)查 2014年3月，選取五侯村、孤山口村符合納入標(biāo)準(zhǔn)的村民745例為調(diào)查對(duì)象，采用自制調(diào)查問(wèn)卷進(jìn)行干預(yù)前的基線調(diào)查。2014年8月，再次選取五侯村、孤山口村符合納入標(biāo)準(zhǔn)的村民740例為調(diào)查對(duì)象，采用自制調(diào)查問(wèn)卷進(jìn)行干預(yù)后的終末調(diào)查。納入標(biāo)準(zhǔn)：(1)40～74周歲；(2)既往無(wú)結(jié)直腸癌病史；(3)無(wú)精神障礙和行為異常；(4)調(diào)查期間(持續(xù)3 d)在家且愿意參與調(diào)查。排除標(biāo)準(zhǔn)：無(wú)當(dāng)?shù)貞艏?或)非當(dāng)?shù)爻Ｗ∪丝凇２捎萌霊粼L問(wèn)式問(wèn)卷調(diào)查方式，以戶為單位，逐戶進(jìn)行調(diào)查?；€調(diào)查內(nèi)容為一般資料(性別、年齡、職業(yè)、婚姻情況、文化程度、家庭人均月收入、醫(yī)療保險(xiǎn)情況)、結(jié)直腸癌篩查知識(shí)得分[14]、結(jié)直腸癌篩查態(tài)度得分[14]，終末調(diào)查內(nèi)容除基線調(diào)查內(nèi)容外，還包括結(jié)直腸癌篩查消息知曉率、宣傳折頁(yè)獲得率、宣傳海報(bào)關(guān)注率。

1.4 觀察指標(biāo) 記錄兩組一般資料，結(jié)直腸癌篩查消息知曉率、宣傳折頁(yè)獲得率、宣傳海報(bào)關(guān)注率、知識(shí)得分、態(tài)度得分，初篩參與率，腸鏡參與率。

1.5 質(zhì)量控制 問(wèn)卷調(diào)查前對(duì)調(diào)查員進(jìn)行培訓(xùn)，培訓(xùn)內(nèi)容包括問(wèn)卷調(diào)查的要求、問(wèn)卷調(diào)查各項(xiàng)內(nèi)容的詳細(xì)解釋、問(wèn)卷調(diào)查注意事項(xiàng)及技巧等。同時(shí)在問(wèn)卷調(diào)查過(guò)程中有相關(guān)人員進(jìn)行現(xiàn)場(chǎng)督導(dǎo)。

1.6 統(tǒng)計(jì)學(xué)方法 采用EpiData 3.1進(jìn)行數(shù)據(jù)錄入，Stata 12.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析。不符合正態(tài)分布的計(jì)量資料以M(QR)表示，兩組間比較采用Wilcoxon符號(hào)秩檢驗(yàn)；計(jì)數(shù)資料比較采用χ2檢驗(yàn)；干預(yù)前后結(jié)直腸癌篩查知識(shí)得分、態(tài)度得分差值比較采用獨(dú)立混合橫截面數(shù)據(jù)的雙重差分模型分析；初篩參與率、腸鏡參與率比較采用二分類非條件Logistic回歸分析；雙側(cè)檢驗(yàn)水準(zhǔn)α=0.05。

2 結(jié)果

2.1 一般情況 基線調(diào)查共發(fā)放調(diào)查問(wèn)卷745份(對(duì)照組363份、干預(yù)組382份)，回收有效問(wèn)卷707份(對(duì)照組343份、干預(yù)組364份)，有效回收率為94.9%。終末調(diào)查共發(fā)放調(diào)查問(wèn)卷740份(對(duì)照組359份、干預(yù)組381份)，回收有效問(wèn)卷696份(對(duì)照組330份、干預(yù)組366份)，有效回收率為94.1%。兩組干預(yù)前性別、年齡、職業(yè)、婚姻情況、文化程度、家庭人均月收入、醫(yī)療保險(xiǎn)情況與本組干預(yù)后比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。干預(yù)組干預(yù)前性別、年齡、職業(yè)、醫(yī)療保險(xiǎn)情況與對(duì)照組比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；干預(yù)組干預(yù)前婚姻情況、文化程度、家庭人均月收入與對(duì)照組比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。干預(yù)組干預(yù)后性別、年齡、職業(yè)、婚姻情況、醫(yī)療保險(xiǎn)情況與對(duì)照組比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；干預(yù)組干預(yù)后文化程度、家庭人均月收入與對(duì)照組比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表1)。2.2 兩組結(jié)直腸癌篩查消息知曉率、宣傳折頁(yè)獲得率、宣傳海報(bào)關(guān)注率比較 干預(yù)組結(jié)直腸癌篩查消息知曉率〔93.7%(343/366)〕高于對(duì)照組〔77.6%(256/330)〕，差異有統(tǒng)計(jì)學(xué)意義(χ2=37.689，P<0.001)；干預(yù)組結(jié)直腸癌篩查宣傳折頁(yè)獲得率〔59.0%(216/366)〕高于對(duì)照組〔13.3%(44/330)〕，差異有統(tǒng)計(jì)學(xué)意義(χ2=154.759，P<0.001)；干預(yù)組結(jié)直腸癌篩查宣傳海報(bào)關(guān)注率〔56.6%(207/366)〕高于對(duì)照組〔11.5%(38/330)〕，差異有統(tǒng)計(jì)學(xué)意義(χ2=154.348，P<0.001)。

2.3 兩組結(jié)直腸癌篩查知識(shí)得分、態(tài)度得分比較 兩組干預(yù)后結(jié)直腸癌篩查知識(shí)得分、態(tài)度得分均高于本組干預(yù)前，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；干預(yù)組干預(yù)前后結(jié)直腸癌篩查知識(shí)得分均高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；干預(yù)組干預(yù)前結(jié)直腸癌篩查態(tài)度得分與對(duì)照組比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；干預(yù)組干預(yù)后結(jié)直腸癌篩查態(tài)度得分高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表2)。

表1 兩組干預(yù)前后一般資料比較

注：-為無(wú)此項(xiàng)；對(duì)照組干預(yù)前343例、干預(yù)后330例，干預(yù)組干預(yù)前364例、干預(yù)后366例

2.4 兩組干預(yù)前后結(jié)直腸癌篩查知識(shí)得分差值比較 分別以干預(yù)前后結(jié)直腸癌篩查知識(shí)得分、態(tài)度得分差值為因變量，組別(賦值：干預(yù)組=1，對(duì)照組=0)、時(shí)點(diǎn)(賦值：基線=0，終末=1)、組別與時(shí)點(diǎn)的交互項(xiàng)、性別(賦值：男=1，女=2)、年齡(賦值：40～歲=1，50～歲=2，60～歲=3，≥70歲=4)、職業(yè)(賦值：農(nóng)民=1，非農(nóng)民=2)、婚姻情況(賦值：無(wú)配偶=1，有配偶=2)、文化程度(賦值：文盲=1，小學(xué)=2，初中=3，高中及以上=4)、家庭人均月收入(賦值：<1 500元=1，1 500～3 500元=2，≥3 500元=3)、醫(yī)療保險(xiǎn)情況(賦值：無(wú)醫(yī)療保險(xiǎn)=1，有醫(yī)療保險(xiǎn)=2)為自變量，進(jìn)行獨(dú)立混合橫截面數(shù)據(jù)的雙重差分模型分析，結(jié)果顯示：兩組干預(yù)前后結(jié)直腸癌篩查知識(shí)得分差值比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05，見(jiàn)表3)；干預(yù)組干預(yù)前后結(jié)直腸癌篩查態(tài)度得分差值大于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表4)。

2.5 初篩參與率、腸鏡參與率 干預(yù)組和對(duì)照組的初篩參與率分別為35.6%(324/911)、11.6%(109/936)，初篩陽(yáng)性例數(shù)分別為36、28例，腸鏡參與率分別為22.2%(8/36)、39.3%(11/28)。

2.6 兩組初篩參與率、腸鏡參與率比較 分別以初篩參與率、腸鏡參與率為因變量，組別(賦值：干預(yù)組=1，對(duì)照組=0)、性別(賦值：男=1，女=2)、年齡(賦值：40～歲=1，50～歲=2，60～歲=3，≥70歲=4)為自變量，進(jìn)行二分類非條件Logistic回歸分析，結(jié)果顯示：干預(yù)組較對(duì)照組初篩參與率高23.8%，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表5)；兩組腸鏡參與率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05，見(jiàn)表6)。

表2 兩組干預(yù)前后結(jié)直腸癌篩查知識(shí)得分、態(tài)度得分比較 〔M(QR)，分〕

Table 2 Comparison of scores of knowledge and attitude of colorectal cancer screening before and after intervention between the two groups

組別結(jié)直腸癌篩查知識(shí)得分干預(yù)前 干預(yù)后Z值P值結(jié)直腸癌篩查態(tài)度得分干預(yù)前 干預(yù)后Z值P值對(duì)照組0(2)5(4)-15.173<0.00135(9)36(4)-2.2970.022干預(yù)組0(4)6(3)-16.956<0.00135(9)38(4)-8.703<0.001Z值-2.598-4.455---0.113-7.855--P值0.009<0.001--0.910<0.001--

注：-為無(wú)此項(xiàng)；對(duì)照組干預(yù)前343例、干預(yù)后330例，干預(yù)組干預(yù)前364例、干預(yù)后366例

表3 兩組干預(yù)前后結(jié)直腸癌篩查知識(shí)得分差值比較的獨(dú)立混合橫截面數(shù)據(jù)的雙重差分模型

Table 3 DID model of independent pooled cross-sectional data of comparison of knowledge score of colorectal cancer screening before and after intervention between the two groups

變量回歸系數(shù)95%CISEt值P值常數(shù)項(xiàng)1.244(-1.237,3.725)1.2650.980.325組別0.389(0.026,0.751)0.1852.100.036時(shí)點(diǎn)3.433(3.070,3.797)0.18518.54<0.001組別與時(shí)點(diǎn)的交互項(xiàng)0.324(-0.179,0.827)0.2561.260.207性別0.444(0.160,0.727)0.1453.070.002年齡-0.071(-0.155,0.013)0.043-1.650.098職業(yè)0.571(0.006,1.136)0.2881.980.048婚姻情況0.215(-0.266,0.695)0.2450.880.380文化程度0.397(0.221,0.573)0.0904.43<0.001家庭人均月收入(元)a 1500～<3500-0.011(-0.314,0.291)0.154-0.070.941 ≥35000.151(-0.922,1.225)0.5500.280.782醫(yī)療保險(xiǎn)情況-1.100(-3.469,1.270)1.208-0.910.363

注：a表示以家庭人均月收入<1 500元為參照

表4 兩組干預(yù)前后結(jié)直腸癌篩查態(tài)度得分差值比較的獨(dú)立混合橫截面數(shù)據(jù)的雙重差分模型

Table 4 DID model of independent pooled cross-sectional data of comparison of attitude score of colorectal cancer screening before and after intervention between the two groups

變量回歸系數(shù)95%CISEt值P值常數(shù)項(xiàng)34.911(29.676,40.147)2.66913.08<0.001組別0.460(-0.306,1.225)0.3901.180.239時(shí)點(diǎn)1.769(1.002,2.536)0.3914.53<0.001組別與時(shí)點(diǎn)的交互項(xiàng)1.671(0.610,2.733)0.5413.090.002性別1.560(0.961,2.158)0.3055.11<0.001年齡-0.028(-0.205,0.150)0.090-0.310.760職業(yè)1.136(-0.055,2.328)0.6071.870.062婚姻情況-0.346(-1.360,0.667)0.517-0.670.503文化程度0.398(0.027,0.770)0.1892.100.036家庭人均月收入(元)a 1500～<3500-0.090(-0.728,0.548)0.325-0.280.782 ≥3500-0.116(-2.381,2.149)1.154-0.100.920醫(yī)療保險(xiǎn)情況-2.552(-7.552,2.449)2.549-1.000.317

注：a表示以家庭人均月收入<1 500元為參照

表5 兩組初篩參與率比較的二分類非條件Logistic回歸分析

Table 5 Binary non-conditional Logistic regression analysis of comparison of participation rate of preliminary screening between the two groups

項(xiàng)目dy/dx95%CISEZ值P值組別0.238(0.201,0.274)0.01912.81<0.001性別0.151(0.115,0.187)0.0188.22<0.001年齡0.018(0.008,0.028)0.0053.400.001

表6 兩組腸鏡參與率比較的二分類非條件Logistic回歸分析

Table 6 Binary non-conditional Logistic regression analysis of comparison of colonoscopy participation rate between the two groups

項(xiàng)目dy/dx95%CISEZ值P值組別-0.174(-0.405, 0.056)0.118-1.480.139性別0.009(-0.240, 0.258)0.1270.070.942年齡-0.060(-0.118,-0.002)0.030-2.040.041

3 討論

3.1 基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式較大程度提高了村民接觸結(jié)直腸癌篩查信息的程度 本研究結(jié)果顯示，干預(yù)組結(jié)直腸癌篩查消息知曉率、宣傳折頁(yè)獲得率、宣傳海報(bào)關(guān)注率均高于對(duì)照組，說(shuō)明基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式有效提高了村民結(jié)直腸癌篩查消息知曉率和結(jié)直腸癌篩查相關(guān)信息接觸水平。在我國(guó)，農(nóng)村地區(qū)普遍呈現(xiàn)地廣人稀、相對(duì)封閉的現(xiàn)狀，導(dǎo)致廣泛的信息覆蓋受到影響，同時(shí)由于村民忙碌的生活狀態(tài)、較低的文化程度以及薄弱的健康保健意識(shí)，即使在特定地點(diǎn)擺放大量宣傳折頁(yè)、海報(bào)、橫幅，也較難引起村民的注意并從中獲得信息。本研究采用村委會(huì)廣播通知、社區(qū)領(lǐng)袖協(xié)助發(fā)放宣傳折頁(yè)、社區(qū)領(lǐng)袖劃分區(qū)域入戶口頭告知等干預(yù)形式，為更多的人參與結(jié)直腸癌篩查創(chuàng)造了前提條件。與此同時(shí)，干預(yù)組仍有部分村民不知曉篩查消息，針對(duì)這部分村民，應(yīng)采取其他措施如社區(qū)領(lǐng)袖進(jìn)行電話告知等形式。

3.2 基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式較大程度提高了村民結(jié)直腸癌篩查參與行為 篩查參與率是反應(yīng)干預(yù)效果的重要指標(biāo)，直接反映整個(gè)干預(yù)方案是否有效。本研究結(jié)果顯示，干預(yù)組較對(duì)照組初篩參與率高23.8%，說(shuō)明基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式提高了村民的篩查參與行為；干預(yù)組與對(duì)照組腸鏡參與率無(wú)差異，可能與其影響因素多樣、高危人群較少等原因有關(guān)。與其他研究者設(shè)計(jì)各種干預(yù)方案提高癌癥篩查參與率的研究結(jié)果一致，其癌癥篩查參與率提高10%～25%[15-17]，而本研究初篩參與率提高了23.8%，基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式的效果更顯著。其原因可能主要為以下兩方面：一方面，社區(qū)領(lǐng)袖大力協(xié)助項(xiàng)目組進(jìn)行廣播通知、宣傳折頁(yè)發(fā)放和入戶告知，提高了結(jié)直腸癌篩查消息的覆蓋率，從而為提高初篩參與率創(chuàng)造了良好的前提條件；另一方面，社區(qū)領(lǐng)袖通過(guò)示范性篩查和個(gè)性化勸導(dǎo)等手段，使村民降低對(duì)結(jié)直腸癌篩查項(xiàng)目的戒心、真正理解結(jié)直腸癌篩查的好處、感受到群體壓力等從而改變參與行為，積極參與篩查。

3.3 基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式對(duì)村民結(jié)直腸癌篩查知識(shí)、態(tài)度的影響不大 雙重差分模型常用于對(duì)公共政策或項(xiàng)目干預(yù)實(shí)施效果的定量評(píng)估，將“前后差異”和“有無(wú)差異”有效結(jié)合，通過(guò)建模來(lái)有效控制研究對(duì)象間的事前差異，將干預(yù)的真正結(jié)果(凈效果)有效分離出來(lái)[18]。本研究基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式更注重通過(guò)社區(qū)領(lǐng)袖示范性篩查、群體壓力等方式直接改變村民的篩查參與行為，雖然干預(yù)過(guò)程中同時(shí)采用了張貼宣傳海報(bào)、廣泛發(fā)放宣傳折頁(yè)等健康教育手段，但由于村民文化程度低、對(duì)健康知識(shí)的可接受程度小等原因，導(dǎo)致雖然對(duì)照組、干預(yù)組干預(yù)后結(jié)直腸癌篩查知識(shí)得分、態(tài)度得分均高于本組干預(yù)前，但干預(yù)組和對(duì)照組干預(yù)前后結(jié)直腸癌篩查知識(shí)得分差值無(wú)差異。對(duì)于結(jié)直腸癌篩查態(tài)度得分，本研究主要是從疾病的嚴(yán)重性、疾病的易感性、篩查的好處、篩查的障礙及自我效能5個(gè)方面進(jìn)行衡量[13]，結(jié)果表明，干預(yù)組干預(yù)前后結(jié)直腸癌篩查態(tài)度得分差值大于對(duì)照組，這可能是由于社區(qū)領(lǐng)袖通過(guò)自身示范、與社區(qū)醫(yī)務(wù)人員搭檔入戶進(jìn)行個(gè)性化勸導(dǎo)等方式，讓村民更加相信結(jié)直腸癌篩查的好處和自我效能等，所以結(jié)直腸癌篩查態(tài)度得分較高。

3.4 本研究局限性 因?yàn)楸狙芯績(jī)H選擇了2個(gè)村進(jìn)行研究，并且因?yàn)槌鹾Y高危人群較少，故兩組腸鏡參與率無(wú)差異；同時(shí)，因?yàn)檗r(nóng)村“人戶分離”現(xiàn)象較嚴(yán)重，調(diào)查期間不在家的村民并未調(diào)查到，可能存在選擇偏倚。

綜上所述，本研究組設(shè)計(jì)的基于CBPR的農(nóng)村結(jié)直腸癌篩查組織動(dòng)員模式雖然對(duì)村民的結(jié)直腸癌篩查知識(shí)掌握情況、態(tài)度影響較小，但有效提高了其初篩參與率，干預(yù)效果較好。因此，在農(nóng)村開(kāi)展結(jié)直腸癌篩查工作，應(yīng)充分利用CBPR的思想設(shè)計(jì)與農(nóng)村人群特點(diǎn)相適應(yīng)的組織動(dòng)員干預(yù)方案，通過(guò)組建社區(qū)篩查小組、基線調(diào)查了解現(xiàn)狀、社區(qū)領(lǐng)袖樹(shù)立篩查模范、社區(qū)領(lǐng)袖協(xié)助宣傳教育、社區(qū)領(lǐng)袖帶領(lǐng)社區(qū)醫(yī)務(wù)人員入戶進(jìn)行個(gè)性化勸導(dǎo)等綜合性干預(yù)措施提高村民結(jié)直腸癌篩查參與率，從而進(jìn)一步提高結(jié)直腸癌早診率，降低結(jié)直腸癌病死率。

作者貢獻(xiàn)：楊文珍進(jìn)行研究設(shè)計(jì)、研究實(shí)施、資料收集并撰寫(xiě)論文；王亞?wèn)|進(jìn)行整體研究質(zhì)量控制及審校；王貴齊、徐俊杰進(jìn)行研究現(xiàn)場(chǎng)篩查工作的實(shí)施；劉茉進(jìn)行資料收集與數(shù)據(jù)整理。

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(本文編輯：崔麗紅)

Effectiveness Evaluation of Mobilization Model of Colorectal Cancer Screening in Rural Area on the Basis of Community-based Participatory Research Method

YANGWen-zhen1,WANGYa-dong1*,WANGGui-qi2,XUJun-jie3,LIUMo1

1.SchoolofHealthManagementandEducation,CapitalMedicalUniversity,Beijing100069,China2.DepartmentofEndoscopy,CancerHospitalChineseAcademyofMedicalSciences,Beijing100021,China3.CommunityHealthServiceCentersofHancunheTown,Beijing102423,China

Objective To evaluate the effectiveness of mobilization model of colorectal cancer screening in rural area on the basis of community-based participatory research(CBPR) method.Methods From March to August in 2014,two villages(Wuhou Village and Gushankou Village) were selected from 27 administrative villages in Hancunhe Town of Beijing as sampling sites for community intervention by purposive sampling method.The two villages were randomly assigned to intervention group(Wuhou Village) and control group(Gushankou Village) by simple random sampling method.There were respectively 911 and 936 villagers met the screening requirements in the Wuhou Village and Gushankou Village.The high-risk factors questionnaire and fecal occult blood test(FOBT)(two times) were used to perform the preliminary screening among these targeted populations,and colonoscopy was given to high-risk populations.Intervention group adopted the model of mobilization based-on CBPR method while control group used the routine mobilization method for intervention.In March 2014,745 villagers who met the inclusion criteria were selected from Wuhou Village and Gushankou Village as research objects,and the self-made questionnaire was used to conduct baseline survey before intervention.In August 2014,740 villagers of Wuhou Village and Gushankou Village who met the inclusion criteria were selected as the research object,and the final-stage investigation was conducted after self-made questionnaire intervention.The general information,the awareness rate of information,acquiring rate of poster foldout,interest rate of propaganda poster,score of knowledge and score of attitude of colorectal cancer screening,participation rate of preliminary screening and participation rate of electron endoscopy were recorded.Results A total of 745 questionnaires(363 in control group and 382 in intervention group) were sent out in the baseline survey,and 707(343 in control group and 364 in intervention group) were valid with an effective response rate of 94.9%.A total of 740 questionnaires(359 in control group and 381 in intervention group) were sent out in the final-stage survey,and 696(330 in control group and 366 in intervention group) were valid with an effective response rate of 94.1%.The awareness rate of information,acquiring rate of poster foldout and interest rate of propaganda poster of colorectal cancer screening in intervention group were higher than those in control group(P<0.05).The score of knowledge and score of attitude of colorectal cancer screening after intervention in the control group and intervention group were higher than those before intervention(P<0.05).The scores of knowledge of colorectal cancer screening before and after intervention in intervention group were higher than those in control group(P<0.05).There was no significant difference in the scores of attitude of colorectal cancer screening before intervention between intervention group and control group(P>0.05);the score of attitude of colorectal cancer screening after intervention in intervention group was higher than that in control group(P<0.05).The results of difference-in-differences model of independent pooled cross-sectional data showed that there was no significant difference in score of knowledge of colorectal cancer screening before and after intervention between the two groups(P>0.05);the difference value of score of attitude of colorectal cancer screening before and after intervention in intervention group was greater than that in control group(P>0.05).The binary non-conditional Logistic regression analysis showed that the participation rate of preliminary screening in intervention group was 23.8% higher than that in control group(P<0.05);there was no significant difference between intervention group and control group in participation rate of colonoscopy(P>0.05).Conclusion The mobilization model of colorectal cancer screening in rural area on the basis of CBPR has greatly improved the awareness of screening information of colorectal cancer screening and participative behaviors of preliminary screening of the villagers,however,due to the low educational level of the villagers,their knowledge and attitude of colorectal cancer screening are less affected.

Colorectal neoplasms;Rural population;Screening;Effectiveness of intervention;Mobilization

北京市科學(xué)技術(shù)委員會(huì)(D121100004712001)——結(jié)腸癌早期預(yù)警及篩查規(guī)范研究

R 735.34

A

10.3969/j.issn.1007-9572.2017.06.004

2016-08-23；

2016-12-26)

1.100069 北京市，首都醫(yī)科大學(xué)衛(wèi)生管理與教育學(xué)院

2.100021 北京市，中國(guó)醫(yī)學(xué)科學(xué)院腫瘤醫(yī)院內(nèi)鏡科

3.102423 北京市，韓村河鎮(zhèn)社區(qū)衛(wèi)生服務(wù)中心

*通信作者：王亞?wèn)|，教授；E-mail：yadong61@ccmu.edu.cn

*Correspondingauthor:WANGYa-dong,Professor;E-mail:yadong61@ccmu.edu.cn