Tổng quan các cách tiếp cận trong nghiên cứu về hành vi tìm kiếm sức khỏe

31 TAP CHi KHOA HQC XA HQI SO 11(l35)-2009 TONG QUAN CAC CACH TIEP CAN TRONG NGHIEN cufu VE HANH VI T I M KIEM SUfC KHOE LE THI NGOC HANH'*' TOM TAT Trong khoa hgc vi swc khde nghien cwu vi hdnh vi tim kiim swc khde giw vi tri rit quan trgng Vi ca ban, nhu'ng nghien cwu cung cip hieu biit giiip danh gia dwgc nhwng hanh vi thwc ti nao cua ngwdi dan cd the tao hieu qua tich cwc vide bao vd swc khde va giam thieu tdc ddng tieu cwc cua benh tat Dong thdi, dwa tren nghien cwu nay, ngwdi ta cd thi dwa cac chiin Iwgc phu hgp de cai thien he thing y ti vd nang cao swc khde cdng dong Tong quan cac nghien cwu va ngoai nwdc ve hanh vi tim kiim swc khde, bai viit gidi thidu cdc md hinh phan tich da dwgc sw dung Tw dd, ggi md mdt so hwdng nghien cwu vi hanh vi tim kiim swc khde a Viet Nam giai doan hidn CAC NGHIEN CIJU TREN T H ^ GIOI Cae edng trinh v l hanh vi tim kiim SCPC khde thudng SLP dyng nhiiu each t i l p can khae Ban d i u , each tiip can nhan thwc, thai do, hanh vi (KAP - Knowledge, Attitudes, Practices) dugc SLP dyng biin, nhien, thdi gian g i n day, eae each t i l p can dan tdc hpc tap trung (FES Focused Ethnographic Studies), md hinh niim tin sue khde (HBM - Health Belief '"' Nghien ciPU vien Trung tam Thong tin, Vien Phat triin Bin vung viing Nam Bp Model), ly thuyit v l hanh ddng cd ly giai (TRA - Theory of Reasoned Action), ly thuyit ve hanh vi cd k l beach (TPB Theory of Planned Behaviour), each t i l p can gidi, tiep can nhdm nhCpng ngudi d l bj ton thuang cang dugc chd y Mdt s l nha nghien CLPU (Maekian, 2003; Hausmann-Muela, Ribera, Nyamongo, 2003) da no lyc t i n g hgp eae each t i l p can tip cac nghien ciru thye nghiem v l hanh vi tim kiem sCre khde d l eung e l p mpt each nhin toan dien v l eae ly thuyit da va dang dwgc sir dung ITnh vyc nghien eCru Trong bai viet eua minh, Hausmann-Muela va eae cdng sy (2003) da t i n g k i t lgi cae md hinh va cae each t i l p can khae nghien eCru v l hanh vi tim kiim sire khde tir trude d i n mdt each cd he thong theo trinh t y logic tir dan gian d i n phirc tap Nhd'ng nghien cd-u ban d i u thudng ap dyng each t i l p can Dieu tra vi kiin thwc, thai va hanh vi (KAP surveys) duge xem la cd uu d i i m Idn viee lugng gia kiln thCre cda epng d i n g nhCrng dy an ldn nhung ed diim yeu la thudng mang nang tinh md ta, chua chf rd ddng ea quyit djnh cda ngudi benh va khdng chd y dung mue d i n sy tac ddng cda eae nhan td xa hpi, van hda Dong thdi, ban than nghien CCPU KAP thudng gia djnh ring viec lam thay ddi kiln thipc se d i n d i n thay d i i hanh vi theo mong dgi ed 32 LE THj NGOC HANH - TONG QUAN CAC CACH TIEP CAN lgi cho sue khde Tuy nhien, ea qua trinh nhan dien cac dang khac eua kiln thLPC d l thu duge thdng tin sy hieu bilt cua ngudi dan ve he thing cham sdc sue khde (kha nang tiep can, he thing chuyen benh, gid md cCpa, viee chi tra djch vu ) cdng ehua dugc thye hien ddng mipc nhd'ng nghien CCPU dang Han nCpa, nhiiu nghien CCPU khac da eho thiy ring, kiln thire edng nhu nhirng nhan to khae se chl anh hudng mpt phin viee thay d i i hanh vi Khle phye nhd'ng han c h l nay, eae nha khoa hpe su' dung nhwng nghien cwu dan tdc hgc tap trung (FES) va danh gia nhanh Sy ap dyng hai phuang phap mpt mat giup phat hien, nhan dien cae phan loai benh tat mang tinh dja phuang, tire la ehd y d i n y i u t l van hda ban dja nhan thuc v l benh tat cda cpng dong, mat khae gidp eho cupc nghien CCPU trd nen linh dpng ban va sau ban vi nhln manh phuang phap nghien CCPU djnh tinh viee tim hilu hanh vi tim kiim SCPC khde eda ngudi dan tgi dja phuang Han nCpa, khong chf du-ng lai d viee mieu ta, each tilp can dan tdc hgc tap trung (FES) vd danh gia nhanh cdn cung c l p md hinh giai thieh nhd'ng hanh vi dd theo nhCpng khudn mau ed t h i tien doan dwgc Nhung ngugc lai, nhirng nghien CLPU it tim hieu sau nhd'ng khia canh eda nhan thipc va mCre dp quan trpng eua viee danh gia nhCpng b i i canh eae k i t qua nghien cCru v l cac tinh hulng thye sy cua ngudi tham gia nghien ciru Cae tilp can theo md hinh niim tin swc khde (HBM) va ly thuyet ve hanh ddng cd ly giai (TRA) va ly thuyet vi hanh vi cd ke hoach (TPB) lai di sau phan tich nhCrng y i u t l ben trong, nhCpng ddng ca d i n den hanh vi tim k i i m sd'c khde Nhd'ng each thipc cho phep md rpng eae nhan t l quyet djnh hanh vi cac nghien euu eua KAP va FES Neu nhu md hinh HBM nhln manh d i n y i u to niim tin ddi vdi hanh vi tim kiem SLPC khde thi ly thuyit TPB (la sy phat trien ban nCpa eua TRA) quan tam d i n cae khia canh dpng ca quan ly benh eua ea nhan va anh hudng eua eae mang ludi xa hpi va ap lye tip nhd'ng ngudi ban cdng the he Tat ca cae md hinh phan tieh tren eho t h i y nhCrng m i i lien he gid'a cac biin s l dugc ddng d l ed the giai thieh va tien doan hanh vi tim kiim SCPC khde Nhu vay, tip md hinh KAP cho d i n mo hinh TPB, ehdng ta thiy cd mdt sy djch chuyen ve each thuc ngudi ta ly giai hanh vi tim k i i m sire khde cua ngudi dan tir md ta hanh vi den tim hieu dpng ea Trong KAP ed uu t h i md ta hanh vi dugc t i i n hanh b i n g phuang phap dilu tra djnh lugng tren dien rpng vdi dung lugng m l u Idn, thi eae md hinh sau nhu FES, HBM, TPB t i i n d i n sy tim kiim nhd'ng dpng ca ben trong, mang tinh chit ban dja cda khu vyc nghien eCru thong qua eae phuang phap djnh tinh Tir c h l n h l n mgnh y i u t l ea nhan nhu y i u t l quyet djnh d i n n h l n manh vao y i u t l xa hpi va nhan t h i y vai trd cang quan trpng eda y i u t l N l u KAP dya tren t i i n de nhan thCre ea nhan tot se d i n d i n hanh vi tim kiim sire khde cd Igi va mang tinh ly tri thi HBM va TPB lai e l g i n g tim them nhCrng y i u t l anh hudng khac nhu niim tin va ddng ca Quan tam d i n nhCrng rao can cda xa hpi anh hudng d i n hanh vi tim kiim sCre khde, Hausmann-Muela va cae cdng sy da gidi iETH! NGOC HANH - TONG QUAN CAC CACH TIEP CAN thieu md hinh b i n chCt' A thudng dugc sd' dung cac nghien cuu trude Md hinh dya tren khung khai niem: (1) Sy ed san (availability); (2) Sy tilp nhan (accessibility); (3) Sy chip thuan v l gia ca cua djch vy: chi phi eho ehd'a tri ca nhan, cho gia dinh hay la eho toan hd; (4) Sy chip nhan (acceptability) Md hinh nhln manh khoang each v l dja ly, kinh t l , xa hpi Nhd'ng khoang each duge xem la nhd'ng rao can film nang hanh vi tim kiim sd-c khde mpt each d i y dd eda ngudi dan, dae biet la ngudi ngheo va phu nd- ngheo Cdch tiip can gidi vd cdch tiip can nhCrng nhdm ngwdi de bi ton thwang quan tam ehinh d i n hanh vi tim kiim sd'c khde eua nhu-ng d i i tugng d l bj t i n thuang Cae each tilp can luu y nhd-ng tac dpng eua c l u trdc xa hdi d khia cgnh b i t binh dang cd t h i la rao can ehinh d i i vdi hanh vi tim kiim sd'c khde eua phy nd' ngheo va ngudi ngheo Cae k i t qua nghien cuu eho thiy d i i vdi phy nd-, s y le thupc eda phy nd' vao dan dng v l kinh t l , sy gia trudng, kiln cda djch vu cham sdc y t l , quan niem trpng nam khinh nd' cua xa hpi da d i y nhd'ng ngudi phy nd' vao t h i bit Igi hp tilp can cae djch vy y t l ; d i i vdi ngudi ngheo ndi ehung, chi phi ehd'a tri (tryc tilp va gian tilp) la rao can ehinh khiln hp khdng nhgn dwgc sy ehd'a tri kjp thdi, d i y dd va cd nhd'ng bien phap phong benh thieh hgp Ben canh xu hudng di td' each md ta hanh vi d i n tim hilu dpng ea, tir viec xem xet cac nhan t l dae d i i m ca nhan d i n nhd'ng rao can xa hpi anh hudng d i n hanh vi tim kiim sire khde, Hausmann-Muela va cac cpng s y cdn chf met xu hudng khac 33 eae md hinh nghien CLPU v l hanh vi tim kiim SCPC khde, dd ehinh la viee cac nghien cd'u chuyen td' chf tap trung vao d i i m d i u (tire la nghien cd'u sau v l kiln thirc) va d i i m euli (sy lya ehpn eae dieh vy cham sdc SCPC khde), d i n viee tap trung nghien CCPU qua trinh eua hanh vi tim k i i m SCPC khde Md hinh KAP nhu da ndi, tap trung vao phan tieh kiln thCpc eua ngudi dan, xem nhu day la y i u t l quan trpng nhit d i i vdi viec quyit djnh hanh vi lya ehpn eae logi hinh djch vy cham sdc SLPC khde Day chinh la md hinh tap trung vao diem d i u Ngugc Igi, tap trung vao diim euli, Md hinh sw dung chdm sdc swc khde Igi dat trpng tam vao viec ngudi dan da lya ehpn nhd'ng hinh thipc ehd'a tri gi va lya ehpn nhu the nao va quan trpng ban tim hilu nhd'ng nhan td khae ed anh hudng d i n lya ehpn eda ngudi dan d mue dp Nhwng md hinh chi rd ve dwdng dan tdi vide tim kiim sw chdm sdc swc khde, chinh la tap trung vao giai dogn gid'a eda hanh vi tim kiim sCre khde Md hinh khao sat qua trinh b i t d i u bing viec nhan bilt trieu chCrng benh, each quyit djnh, quyit djnh t i l p xde vdi dang djch vu y t l nao, sau ehd'a tri thi benh nhan danh gia k i t qua va euli eung la ty nhgn thCre Igi benh tat eda ban than nhu t h i nao Trung tam cda qua trinh chinh la "nhd'ng ngudi ed t l m quan trpng nao dd d i i vdi ea nhan" (cd t h i la b i t ky d i i tugng nao td' ngudi than gia dinh, ban be, thiy lang, bae sT ed uy tin ddi vdi ngudi benh) Nhu vay, b i n g sy lya chpn trinh bay eae md hinh va cae each t i l p can khac thay vi xem xet lai cac k i t qua nghien cd'u v l hanh vi tim kiim sue khde, Hausmann- LE THj NGOC HANH - TdNG QUAN CAC CACH TIEP CAN 34 Muela va eae cdng sy khdng nhCrng da cung c l p mpt bd'c tranh khai quat v l cae phuang phap da dwgc ddng, ma cdn dua nhiiu ban luan phe phan cd gia tri hd-u dung d l eae nghien eCru sau chpn lya dugc each nghien ciru phu hgp vdi hieu qua mong dgi Tdm lai, qua trinh chuyin djch moi quan tam tir each tiep can KAP d i n cac each tilp can dan tpc hpe (FES), md hinh niem tin sCre khde (HBM), ly thuyit v l hanh dpng ed ly giai (TRA), ly thuyit v l hanh vi CO k l hoach (TPB), each t i l p can gidi, tiep can nhd'ng nhdm ngudi bj t i n thuang nil len dae diem ehinh Dd la: - Tir md ta hanh vi den tim hieu dpng ca - Rac can eda hanh vi tim kiim sire khde: tir "ca nhan" d i n "xa hpi" - Chuyin tir tap trung nghien eCru "diim diu", "diim euli" d i n tap trung nghien ciru "qua trinh", tire la giai doan gid'a eda hanh vi tim kiim sire khde So d l khai quat cac md hinh tilp can cung nhu xu hudng biin doi cua chung Md ta Ydu t6 tac dong Qua trinh Hanh vi Ca nhan Diem diu KAP KAP FES HBM KAP TPB HBM 4A TRA Nhung nhom nguoi de bi ton thuong TPB Gioi Nhung mo hinh chi ro ve duong dan toi viec tim kiem su cham soc sifc khoe Mo hinh su" dyng cham soc SLPC khoe Dong ca Xa hoi Diem cuoi' Ngudn: , ong hpp tir Hausmann-Muela; Ribera; Nyamongo, 2003 Sa d l Cac md hinh tilp can nghien euu v l hanh vi tim kiim sue khde Maekian mdt nghien euu eua minh (Maekian, 2003) ehi ba xu hudng chinh nghien ciru v l hanh vi tim kiim sue khde, la: 1) Nghien eCru ve viec sCr dyng he thing cham sdc sCrc khde chinh thirc; 2) Nghien ciru qua trinh dap irng d i i vdi benh tat eda ngudi dan (mye dieh la tim nhd'ng nhan to anh hudng d i n viee su' dung eae ehd'a tri va eae cham sdc y t l eda ngudi dan); 3) Nghien eCru v l "cae epng d i n g t y nhan thiPc" Tip eae each tilp can he thing nghien cu-u v l hanh vi tim kiim sire khde nay, eung gilng nhu Hausmann-Muela, Maekian da phe phan nhCrng hgn c h l cua cae each tilp can khac nhau, d l tren ea sd dd d l xult met hudng tiep can mdi nghien eCru v l hanh vi tim kiim sCre khde, dd ehinh la c i n ap dung each tiep can v i n xa hdi o l u tien, Maekian eho ring nghien euu v l viee sCr dyng he thing cham sdc sire khde chinh thire, ed hai xu hudng chu y i u : 1) Nghien ciru phan loai eae rao can va eae y i u t l quyit djnh n i m giCra benh nhan va djch vy; 2) Nghien CCPU phan logi cac qua trinh hay la eae each thCpc d i n tdi hanh vi tim k i i m SCPC khde Tac gia edng phe phan l i i t i l p can KAP da qua ehd trpng d i n m i i lien he mpt ehilu theo dudng thing gid'a K (kiln thd'C) va P (hanh vi), nd it dwgc sw dung d l phat hien nhd'ng mdi quan he rdng Idn ban giCpa dan s l va sy phat triln eua he thing cham sdc SLPC khde So vdi nghien CLPU cda HausmannMuela va eae edng sy, quan diim dugc Maekian trinh bay ed dpng ban va tap trung ban Dua eude thao luan tdi ITnh vyc mdi va hieu qua ban nghien CCPU LE THj NGOC HANH - TONG QUAN CAC CACH TIEP CAN hanh vi tim k i i m sCre khde, bing each phat trien mpt edng ey eho sy hilu bilt la lam t h i nao dan s l lien quan d i n he thing cham see sire khde, chir khong dan thuin sCr dyng hanh vi tim kiim sCre khde nhu la mpt edng cy d l md ta nhCrng each thiPC dan cac ca nhan lien quan d i n djch vu cham sdc SCPC khde Khi trinh bay nhd-ng each t i l p can gidp tim hilu eae nhan to anh hudng d i n hanh vi tim kiim sCre khde, Maekian edng nhac d i n md hinh niim tin sCre khde (ma tae gia xem la met nhCrng md hinh duge ap dung rdng rai nhit eho nhCrng nghien ciru dang nay) va cho ring md hinh dya tren tiin d l trung tam eda edng e l sire khde e l d i l n la: 1) Sd-c khde chju anh hudng cda hanh vi; 2) Hanh vi la cd t h i thay d i i Chinh day la khuyit diim Idn nhit eda md hinh niim tin, vi theo Maekian nd "da khdng quan tam dung mire tdi nhd'ng b i i canh xa hdi da anh hudng d i n hanh vi tim kiim SCPC khde theo met each thirc r i t phCpc tap" Chinh tai diim nay, tac gia da ban d i n nhCrng nghien eCru ed quan tam d i n nhCrng "bdi canh xa hdi", dd ehinh la cdch tiip can "cdng dong tw nhan thwc" Theo Maekian cd t h i md rdng khai niem "hanh vi tim kiim sCre khde", gidp nha nghien eCru quan tam ddng mire d i n nhirng to xa hpi va tap t h i eua hanh vi tim kiim sCre khde, va sy tuang tac cda ca nhan va xa hpi vdi he thong cham sdc sCre khde Tuy nhien, each t i l p can ma ba muin d l xult bai viit la su dyng v i n xa hdi nhu la met khung phan tich v l hanh vi tim kiim sue khde V l mat thao tac hda khai niem, ed t h i sCr dung djnh nghTa "Vln xa hpi (VXH) la nhd'ng tri thire duge chia 35 se ehung, la sy hilu bilt, cac gia tri, cac ehuin mye, nhirng net tieu biiu va he thing eae mdi quan he d l dam bao nhCrng k i t qua dy tinh" (Dhesi, 2000, tr 201) V l md hinh, tae gia ggi y ed t h i su dung md hinh v l Mdi lien he giira cdc to chwc chinh thwc va khdng chinh thwc (ma tac gia dya tren eae phan tich cua Narayan, 1999) Theo Maekian, viee sd' dung md hinh cd the tao khung phan tieh dae biet ban eho sy phat triln eda he thing cham sdc sire khde: 1) NhCrng sy cung elp mang tinh c l u trdc ehinh thCre: khung lam viec cua cac ehinh saeh, to ehCre can bp, cac djch vu edng va tu va nhCrng ngudi cung c l p cae djch vu nay; 2) NhCrng t l chirc khdng chinh thirc vdi nhd'ng anh hudng v l mat SCPC khde t i i m tang nhu la nhd'ng thiy lang truyin thing, eae loai ludi quan he xa hdi Mdi lien k i t giao md hinh duge tgo nen bdi mpt logt nhan t l xa hdi ddng gdp mdt each tiem nang cho tinh trang khde manh bao g i m ea vj tri eda phy nCp xa hpi, sy c l k i t eua epng dong va sy tham gia dan sy Maekian edng d l xult SLP dyng cae edng cy thu thap thdng tin nhu thao luan nhdm, phdng v l n sau la thich hgp cho each tilp can ap dung md hinh v l n xa hpi Tdm lai, bing each trinh bay tap trung han, Maekian da c l g i n g dua mpt triln vpng viee ap dung khung phan tich dya tren khai niem v l n xa hpi vao nghien CLPU hanh vi tim kiim SCPC khde Vdi each thCpc nay, Maekian tin ring se gidp khle phue nhd'ng nhugc d i i m eua cac nghien cd-u sudung md hinh KAP hay md hinh niem tin SLPC khde Ddng thdi, bai viit eung cung c l p kha d i y dd edng cy d l hien thye hda y tudng cua minh, td' thao tae hda khai 36 LE THj NGQC HANH - TONG QUAN CAC CACH TIEP CAN niem, md hinh phan tieh, d i n cac edng eu thu thap thdng tin Mae dd sy tdng hgp ca sd ly luan ve ehu de hanh vi tim kiim sire khde chi mdi duge Hausmann-Muela, Maekian va mpt s l tae gia khae luu y thdi gian g i n day, nhung nhd ed nguin du- lieu ldn tip eae cdng trinh thye nghiem da ed s i n nen da gidp eae nha nghien CLPU nhanh ehdng dua duge nhCpng md hinh phan tieh da dgng va thieh dung eao NHIJNG NGHIEN CU'U TRONG NUCyC Cac nghien CLPU v l hanh vi tim kiem sipc khde treng nude thudng SLP dung each t i l p can KAP Cac chu d l thudng ap dyng each tiep can la: 1) Cham sdc SCPC khoe ba me, tre em (eae nghien ciru eu the: kiln thirc, thai dp, hanh vi dilu tri tre tieu chay tai nha; cham sdc sire khde sinh san phu nd' d ndng thdn; hien tugng thira can d tre); 2) HIV (cae nghien euu ey t h i : hanh vi tinh dye, thye trang va nguyen nhan eda eae benh lay theo dudng tinh dye, wdc tinh va d y bao nhiim HIV d Viet Nam) Cac nghien eCru thudng dwgc tiin hanh tren phgm vi rdng (dilu tra e l p tinh trd len), dung lugng m l u Idn vdi cdng ey nghien eCru ehinh la bang hdi (tren dudi 500 ngudi) Vdi dac diim vCra neu, each t i l p can ed uu diim la gidp thu thgp duge cac thdng tin mang tinh tdng quat cao tren dien rdng, cung e l p nhd'ng thdng tin ea ban ve kiln thire, thai dp, hanh vi eda ngudi dan d i i vdi met so loai benh tat dang phd biin epng dong Tuy nhien, KAP khdng phai la edng eu de nghien cd-u sau v l ddng ea ben d i i vdi cac hanh vi tim kiim SLPC khde, nhit la nd khdng xae djnh dugc nhd'ng yeu t l ve van hda, xa hdi mang tinh edng ding von tae ddng r i t ldn d i n hanh vi eda ngudi dan eae qudc gia dang phat triln Ben canh each t i l p can KAP, met s l nghien cipu d nude ta eung t h i hien eae each t i l p can khac ma d dd cae yeu t l xa hpi anh hudng d i n hanh vi tim kiim sue khde dugc ndi d i n rd net ban Mpt cae each t i l p can dd la md hinh Bon chw A - thudng t h i hien d nhCpng nghien CCPU v l he thing cac djch vy cham soc sd-c khoe d Viet Nam nhu la mpt y i u t l quan trpng anh hudng den s y lya chpn loai hinh djch vu cham sdc SLPC khde eda ngudi dan Cach t i l p can hinh dung cac djch vu cham sdc sd-c khde von r i t da dang cda nude ta hai khu vyc ehinh la djch vu y t l edng epng va djch vu y t l tu nhan Tren ea sd dd, eae tae gia (Nguyin Thj Hing Ha, 2002; Trinh Hda Binh, Thanh Trudng, 2004; Dang Thanh True, 2008) da phan tieh eae dae trung v l sw cd san (availability), sw tiip can (accessibility), sw chip thuan vi gia ca cua dich vu va sw chip nhan (acceptability) cda ngudi dan thupc eae khu vyc cu trd khae va ed cae dae d i i m xa hpi khae d hai logi hinh djch vu Kltiqua nghien CCPU cho thiy nhd'ng khudn m l u v l hanh vi tim kiim SLPC khde cua ngudi dan ddi vdi djch vy y t l t u nhan va djch vy y t l edng ed khae biet Idn Ngudi dan thudng tim d i n djch vu y t l t u ddi vdi eae can benh e l p tinh, benh nhe, m u i n tilt kiem thdi gian va mudn dugc thoai mai ve tam ly thai dp phye vu benh nhan d eae djch vy y t l tu nhan duge danh gia la t i t ban Ngugc Igi, benh nhan se sd' dung dich vu y t l edng cpng k*"' hp m u i n SLP dyng bao bilm y t l , phai nam vien, ehd'a cae benh man LE THI NGOC HANH - TONG QUAN CAC CACH TIEP CAN tinh, cac benh nang ma ca sd y t l tu nhan khdng du trang thilt bj eung nhu y bae sT ed trinh dp NhCpng nghien CCPU eho thiy mac du eae y i u to v l sw cd san, sw tiip can cd anh hudng quan trpng d i n sy lya ehpn loai hinh djch vu y t l eda ngudi dan; y i u t l sw chip thuan vi gia ca cua dich vu va sw chip nhan mdi la nguyen nhan chinh cua sy lya chpn Mdt nhd'ng each t i l p can dugc sw dung kha biin nghien CCPU v l hanh vi tim kiim sd-c khde d nudc ta la md hinh thwc hidn cham sdc swc khde (health care utilization model), Cach tilp can cho rang ngudi cd sy dpe lap nhit djnh viee eae quyit djnh va thye hien hanh vi cua minh d cae ITnh vyc khae eua ddi sing xa hdi, thi d i n g thdi hp cdng ehju anh hudng cua mdi trudng sing, hoan canh sing hay ndi mpt each khai quat ban la e l u true xa hpi, NhCpng nghien cu-u v l chu d l dan s l k l hoach hda gia dinh thudng t h i hien each tilp can Mdt s l tac gia (Nguyin Quang Vinh; Nguyin Thu Sa, 1990) khao cd-u nhCpng y i u t l anh hudng d i n hanh vi thye hien eae bien phap k l hoach hoa gia dinh d eu dan Dong bang sdng CLPU Long da d i n g thdi vira chu y d i n eae dae diim nhan khiu xa hpi (gidi tinh, lira tuoi, thu nhap, hpe vln) vira chu y d i n eae y i u t l thudc v l cau trdc xa hdi cua epng ding dan (trinh dp phat triln kinh t l , tap quan, truyin thing, van hda dja phuang) Caeh tilp can gidp phan tich sau han dpng ca cua hanh vi tim kiim sire khde eda eon ngudi, d i n g thdi edng mang tinh toan dien ban dat hanh vi tim kiim sire khde eua eon ngudi mpt c l u true xa hdi rpng ldn ban 37 Mdt nhd'ng hudng tilp can thudng dugc SLP dung nghien CCPU ve hanh vi tim kiim sire khde la each tilp can gidi Mpt s l tac gia (Nguyen Dd-e Chinh 2003; Nguyin Hu'u Minh; Vd Manh Lgi, 2007) da ap dung eae cdng cy phan tieh gidi va cac nguyen t i e phan tieh gidi eae nghien eCru v l chu d l swc khde sinh san, lam me an toan va phan tieh v l n de tiip can dich vu cham sdc swc khde cua phu nw ngheo Caeh t i l p can gidi trd nen dae biet bd'u dyng phan tieh banh vi tim kiim sire khde cua ngudi dan eae nude dang phat trien, ma eu t h i la d Viet Nam Nd quan tam d i n d i i tugng phy nd' thudng la nhCrng ngudi cd nhiiu rdi ro ve SCPC khde va phai ganh vac nhiiu trach nhiem ban viee phdng benh va ehCpa benh eho eae vien khae gia dinh Nhung chinh hp lai it sd hCpu cac nguon lye, va it ed quyin quyit djnh gia dinh lien quan d i n viec cham sdc SLPC khde Cach tiip can nhdng nhdm ngwdi de bi ton thwang dugc sir dyng r i t phd biin h l u hit eae ehd d l nghien eCru (hanh vi SLP dung bao hiim y t l , benh lao, SLPC khde phy nir, sy lya chpn loai hinh djch vy cham see sire khde, ) cac tac gia phan tieh v l nhirng rao can anh hudng d i n kha nang thye hien hanh vi tim kiim SLPC khde theo hudng tich eye d ngudi dan, dac biet la d eae d i i tugng de bi t i n thuang (ngudi ngheo, ndng dan, phy nCr) Trong chf rd sy khae biet v l thye trgng sire khde, eae thdi quen ve phong benh va kham chd-a benh d nhd-ng nhdm xa hpi khae nhau, eae tae gia da chf sy b i t binh d i n g d eae e l p dp khae d i u anh hudng d i n thye trang sd-c khde va 38 LETHj NGOC HANH - TONG QUAN CAC CACH TIEP CAN cac khudn m l u hanh vi tim kiem sire khde nhu t h i nao Tu' e l p dp ea nhan (sy chenh lech v l hpc v l n , thu nhap), den c l p dp epng dong (ndng thdn-thanh thj, miin nuidong bang), va d i n cap dp van hda (cac niem tin, phong tyc, tap quan, lien quan den hanh vi tim kiim sd'c khde cua ngudi dan) Loi tiep can nhCrng nhom ngudi bj ton thuang giup soi rpi vao nguyen nhan n i n tang cua sy khac biet hanh vi tim kiem sire khde cua nhiiu tang Idp xa hpi, giup nha nghien ciru phat hien nhCrng mau thuin ben mdi he thing xa hpi da anh hudng d i n sy b i t binh dang viee cham soc sire khde cua ngudi dan nhu t h i nao KET LUAN VA DE X U A T MO HJNH PHAN TICH Cac phuang phap dwgc SLP dung nhCpng nghien CLPU cung eho thiy sy phong phu va cd tinh k l thu-a cac each tiep can dugc dung tren t h i gidi nhung nhin chung each tiip can KAP, each tiip can gidi, each tiip can ton thwang va md hinh thwc hien cham sdc sii'c khde {health care utilization model) thudng duge su' dung nhiiu NhCrng each t i l p can eung vdi cac cdng cu thu thap thong tin ca djnh lugng l l n djnh tinh da lam eho k i t qua nghien ciru v l hanh vi tim kiim sire khde d nude ta vira the hien dugc nhd'ng net chung cua v l n d l nghien ciru, vira phan anh duge nhCrng trudng hgp cu the, dac thd vao d i i tugng nghien cd-u Nhung mpt dieu d l nhan thiy qua nhd'ng cong trinh chdng tdi khao ciru d tren la h l u h i t ehdng d i u theo mpt c l u true: thye trang-nhu-ng y i u t l tac dpng Ngoai ra, cac nghien cd-u thudng tap trung vao d i i m d i u va d i i m euli phan tich hanh vi tim k i i m sire khde cua ngudi dan Cu t h i la eae tae gia thudng md ta thye trang sire khde, nhan thire v l benh tat cua ngudi dan va cac sy lya chpn djch vu cham sdc sire khde cua hp Nhu vay, ve mat phuang phap nghien ciru, ein ap dung manh me han nhCrng md hinh phan tieh sau v l dpng ca ben cua ngudi benh cdng nhu v l qua trinh tim kiim sCre khde eua hp (HBM, TRA, TPB) Cd nghTa la nha nghien ciru khdng chf quan tam den giai doan d i u (nhan thirc v l benh tat) va giai doan sau (sy lya chpn djch vu cham sdc sire khde) ma edn ehd y d i n giai doan giCpa (sy tae dpng cda nhCpng ngudi ed uy tin d i n hanh vi tim kiim sd-c khde eua ngudi benh, qua trinh len k l hoach cung nhu quyit djnh chira tri cua ngudi benh) va giai doan hau kham benh (danh gia hieu qua chCra tri va dua ehiln lugc k i i m soat benh tat tuang lai) Dya tren sy t i n g quan cac edng trinh nghien CLPU tren the gidi va nudc v l hanh vi tim k i i m SLPC khde, chdng tdi d l xult mpt md hinh phan tieh khai quat vdi nhd'ng dac diem ehinh: - Ddi tugng nghien cipu: Hanh vi tim kiim sire khde - Hanh vi tim kiim sire khde bao g i m cac t l dugc sap x l p theo mpt chu trinh khep kin t h i hien qua trinh cham sdc sire khde cua ngudi dan: 1) Nhan thire v l benh tat (Hausmann-Muela, 2003), 2) Dy djnh hanh dpng, 3) Hanh dpng - Cae y i u t l tae dpng d i n hanh vi tim kiim sire khde eua ngudi dan dugc phan thanh: 1) Dae d i i m nhan khiu - la y i u t l i::E_TH!NGOC HANH - TONG QUAN CAC CACH TIEP CAN 39 tac dpng tryc tilp; 2) Cae y i u t l vT mo - la y i u t l tae ddng gian tilp • thudc tinh miin Tay Nam Bd Tap chi Y hpc Dy phdng Tap Vlll, s l (36) Phu ban TAI LIEU THAM KHAO 10 Maekian 2003 Tong quan ve hanh vi tim kiim swc khde: Cac vin de va thin vgng, Dai hpe Manchester Duong Huy Lieu, Le Thj Hing Thom 1998 Y te ca sd va cham sdc swc khde sinh san phu nw ndng thdn Tap chi Y hpc Du phong 2005 Tap XV, s l (73) Phu ban Dang Nguyen Anh 2007 Nhu'ng yiu td quyit djnh kha nang tiip can bao hiim y ti d VietNam Tap chi Xa hpi hpc s l (97) Dang Thanh Trdc 2008 Vin di cham sdc siic khde ngwdi dan dwdi tie ddng ciia dd thi hda a phd Da Ning Tap chi Xa hpi hpc so (102) Do Thai Oing 1990 Chinh sach dan si boi canh kinh te-xa hdi cua dong bang sdng Cwu Long Tap ehi Xa hoi hoc s l (30) Hausmann-Muela, Ribera, Nyamongo 2003 Hanh vi tim kiem swc khde vd cac dap wng cua he thong cham sdc sii-c khde Kenya Ha Thdc Dung 2007 Kien thwc vi HIV/AIDS va each phdng chong HIV/AIDS ciia thieu nien Trong: Vien Khoa hpc Xa hpi Viet Nam NhCrng nghien cwu xa hdi hgc thdi ky chuyen ddi Ha Npi: Nxb Khoa hpc Xa hpi Johansson 2000 Gidi va sw kiim soat benh lao: Mgt bii-c tranh vi hanh vi tim kiim swc khde giwa nam gidi va nw gidi Viet Nam Tap chi Health Policy 52 (2000) 11 Nguyin Dwc Chinh 2003 Mdt so khia canh xa hdi ciia vin di swc khde sinh san va lam me an toan Tap chi Xa hoi hoc s l (82) 12 Nguyin Huu Minh, Vu, Manh Lgi 2007 Mdt so vin di dat vi viec tiip can dich vu cham sdc swc khde ciia phu nw ngheo Tap chi Khoa hpc Xa hpi s l 06 (106), 13 Nguyen Phuang Hoa, Anna E K Thorson, Nguyen Hoang Long va Vinod K Diwan 2003 Kiin thwc vi benh lao va hanh vi lien kit tim kiim swc khde giwa nhwng ngwdi trwdng d ndng thdn Viet Nam ddi vdi chwng benh ho it nhit ba tuin Tap ehi Scand J Public Health 31 (Suppl 62) 14 Nguyin Quang Vinh 1990 Ke hoach hda gia dinh d ddng bang sdng Cwu Long, nhin tw giac loi sdng Tap chi Xa hpi hpe, s l (30) 15 Nguyen Thi Hong Ha, Peter Berman va Ulla Larsen 2002 Chi tieu va sw dung dich vu swc khde cdng va tw ciia hd gia dinh d Viet Nam Tap chi Health Pelicy and Planning- 17(1) 16 Nguyin Thj Thanh Thuy 1998 Hanh vi tinh due nguy ca cao vi nhiem HIV d phu nw lam viec nai dich vu giai tn a mien Nam Viet Nam Tap chi Y hpc Dy phong, tap Vlll, s l (36) Phu ban Le Bach Quang 1998 Diiu tra tinh trang cac benh lay truyin theo dwdng tinh due va mgt sd yeu to lien quan tren nhdm ngwdi cd nguy ca cao a tinh phd Tap chi Y hpc Du phong Tap Vlll, s l (36) Phu ban 19 Nguyen Thu Sa 1990 Ke hoach hda gia dinh a ddng bing sdng Cwu Long Tap chi Xa hpi hpc, s l (30) Le Van Son 1998 Tham dd KAP vi dieu th tre tieu chay tai nha ciia phu nw huyen 20 Nguyen Trin Hiin 1998 LTdc tinh va dubao nhidm HIV d Viet Nam, 1996-2000 Tap 40 LE THj NGQC HANH - TONG QUAN CAC CACH TIEP CAN chi Y hpc Dy phdng, tap Vlll, so (36) Phu ban cwu xa hdi hgc thdi ky chuyen ddi Ha Npi: Nxb Khoa hpe Xa hpi 21 Pham Bich San 1990 Mdt s6 gia thiit ve mwc sinh giam nhanh d miin Nam Viet Nam Tap chi Xa hpi hpc, s l (30) 27 Trin Thj Nhung 2009 Sao hiim y te Han Qudc: Thanh twu va nhwng vin di Tap chi Nghien cuu Gia dinh va Gidi s l (2009) 22 Pham Thanh Duy, Phan Thanh Ldi 2005 Khao sat vi chi tieu y ti va sw dung bao hiem y te viec kham chwa benh ciia ngwdi dan Thanh phd Hi Chi Minh Trong: Nguyen T h i NghTa, Mac Dudng; Nguyin Quang Vinh (Chu bien) Dd thi hda va vin de giam ngheo d Thanh phi Hd Chi Minh - Ly luan va thwc tien Nxb Khea hpc Xa hpi 28 Trinh Hoa Binh 2007 Bao hiim y ti: nhu ciu va kha nang md rdng d ndng thdn Tap ehi Xa hpi hpc s l (97) 23 Quy Dan s l Lien Hiep Quic, Ting cue Thing ke 2006 Diiu tra di cw Viet Nam nam 2004: Di dan vd swc khde Viet Nam 24 Trinh Quang Huin 1998 Sit Dengue/sit xuit huyit Dengue d mdt sd tinh miin nam thwc trang, nguyen nhan va giai phap Tap chi Y hpe Dy phdng, tap Vlll, s l (36) Phu ban 25 Trin Thj Hing Loan 1998 Thwa can va cac yeu to nguy ca d hgc sinh 6-11 tudi, Quan 1, Thanh phd Hd Chi Minh Tap ehi Y hpc Dy phong, tap Vlll, s l (36) Phu ban 26 Trin Thai Ngpc Thanh 2007 Chi tieu cho y te ciia hd gia dinh (trwdng hgp xa Khanh Mau - huyen Yen Khdnh va phwdng Van Giang - thi xa Ninh Binh) Trcng: Vien Khoa hpe Xa hpi Viet Nam Nhwng nghien 29 Trinh Hda Binh 2008 Hanh vi swc khde cw dan ndng thdn boi canh xung dot mdi trwdng (nghien cwu trwdng hgp lang nghi Ddng bdng Bdc Bd) Tap chi Xa hpi hpc s l (103) 30 Trinh Hoa Binh, Dao Thanh Trudng 2004 vin di cdng bdng va kha nang cung cip dich vu cham sdc site khde tai cic benh vien tw hien Tap chi Xa hpi hpc so (86) 31 Td Duy Hgp, Nguyen Thj Minh Phuang 2007 An sinh xa hdi d khu vwc ndng thdn Nghien cwu trwdng hgp mdt xa ngoai thinh Ha Ndi Tap chi Xa hpi hpc s l (97) 32 Van Thj Ngpc Lan 1990 Phu nw ndng dan tinh An Giang vdi vin di ki hoach hda gia dinh Tap ehi Xa hpi hpe, s l (30) 33 A Thorson, E Johansson 2004 Sw cdng bang hoac binh ding viec tiip can cham sdc swc khde: Nghien cwu dinh Iwgng vi nhwng giai thich ciia bic sT ddi vdi sw tn hoan lau han giwa nhwng benh nhan TB nwd Viet Nam Tap chi Health Policy 68 41 LETHI NGOC HANH - TONG QUAN CAC CACH TIEP CAN So d l Md hinh phan tich khai quat hanh vi tim kiim sire khoe Cac y i u t i vT m o D a c d i i m nhan khau • • • • • • Trinh dp phat trien kinh tĐ-xa hoi ã Chinh sach cham soc SLfC khoe • Trinh phat trien y hpc Hoc v l n Gioi tinh Ton giao Thu nhap NghĐ nghiep ã SLP s i n c6 cua cac dich vu y t e • V6n xa hoi " Hanh vi tim k i m siPC khoe Nhan \h\'rr vA benh tat • Nhan thuc v§ nhiem benh • Nhan thuc v l nghiem • Nhan thUc v l loi ich • Nhan thuc ve rao can -• ^ D u dinh hanh dpng su • NhCTng nguoi c6 y nghTa tinh • Len ke hoach hanh dong • Ra quyet dinh cac cac Ngudn: Le Thj Ngpc Hanh, 2009 • Hanh dong -ã - Truyen th6ng ã ThĐy lang ã T u chOa tai nha bang cac duoc lieu truySn th6ng - Hien dai • Nguoi ban thuoc • Bae sT (o dich vu y t§ tu/cong) - T u chCPa hay khong chCPa tri ... Khao sat vi chi tieu y ti va sw dung bao hiem y te viec kham chwa benh ciia ngwdi dan Thanh phd Hi Chi Minh Trong: Nguyen T h i NghTa, Mac Dudng; Nguyin Quang Vinh (Chu bien) Dd thi hda va vin de... gia dinh d Viet Nam Tap chi Health Pelicy and Planning- 17(1) 16 Nguyin Thj Thanh Thuy 1998 Hanh vi tinh due nguy ca cao vi nhiem HIV d phu nw lam viec nai dich vu giai tn a mien Nam Viet Nam Tap... Hanh vi tim kiem swc khde vd cac dap wng cua he thong cham sdc sii-c khde Kenya Ha Thdc Dung 2007 Kien thwc vi HIV/AIDS va each phdng chong HIV/AIDS ciia thieu nien Trong: Vien Khoa hpc Xa hpi Viet