基于扎根理论的家庭医生签约服务效果影响机制研究

Mechanisms Affecting the Effectiveness of Contracted Family Doctor Services:a Grounded Theory Analysis

背景当下家庭医生签约服务推行中“签而不知”“签而不约”等问题突出,因此提高家庭医生签约服务效果迫在眉睫。目的对家庭医生签约服务效果的影响机制进行分析。方法于2021年9月至2022年1月,采用目的抽样的方法,对山东省潍坊、菏泽、济南三地市的24名家庭医生、8名机构管理者、25名签约居民进行个人深度访谈。家庭医生访谈提纲内容包括签约政策执行现状、工作现状等;机构管理者访谈提纲内容包括绩效分配、监督管理等问题;机构管理者访谈提纲内容包括签约获得感、希望获得的服务等问题。运用扎根理论的研究方法,经过三级编码对家庭医生签约服务效果及影响机制进行系统研究。结果通过三级编码得到“居民健康意识弱”等90个概念,“签约知晓情况”等24个范畴,“基层卫生服务能力”等8个主范畴。构建了家庭医生签约服务效果影响机制的理论模型,主要包括家庭医生签约服务相关政策执行偏差、基层卫生服务能力及居民特征3条脉络。结论家庭医生签约服务效果受相关政策执行偏差、基层卫生服务能力及居民特征三方面共同影响,因此要优化家庭医生签约服务相关政策执行路径,提高家庭医生医疗卫生服务能力,提升居民健康素养水平。

Background It is urgent to improve the effectiveness of contracted family doctor services due to high prevalence of problems such as uninformed contracting,and contracting but making no appointments.Objective To analyze the mechanism influencing the effectiveness of contracted family doctor services.Methods From September 2021 to January 2022,in-depth interviews were conducted with 24 family doctors,8 institutional managers,and 25 contracted residents purposively sampled from Weifang,Heze,and Jinan of Shandong Province,using an interview guide regarding implementation status of relevant policies and their work status,performance distribution and supervision and management,and sense of gain obtained from the contracting and desired services,respectively.The grounded theory using three levels of coding was used to systematically analyze the mechanism affecting the effectiveness of contracted family doctor services.Results Through the coding,90 concepts(such as"residents’weak health awareness"),24 categories(such as"awareness of the contracting"),and 8 core categories(such as"capacity in primary care")were obtained.A theoretical model of mechanisms influencing the effectiveness of contracted family doctor services was constructed,mainly including the implementation deviation of policies related to contracted family doctor services,capacity of primary care,and characteristics of residents.Conclusion The effectiveness of contracted family doctor services is affected by the deviation in implementing relevant policies,the capacity of primary health services and characteristics of residents.Therefore,to improve the effectiveness of these services,it is necessary to optimize the implementation path of relevant policies,improve family doctors’capacities,and improve residents’health literacy level.