Dch t hc c bn l mt ti liu tham kho rt tt trong hc tp, ging dy v nghin cu trong lnh vc Y t cng cng.

Phin bn 2 ca cun sch ch ra nhng l do ti sao mn dch t c bn li cn thit cho tt c nhng hc vin mun hiu v ng dng nhng nguyn tc trong xc nh cn nguyn v phng nga bnh tt. Cun sch ny cung cp nhng phng php chnh yu ca dch t hc, c bit nhn mnh vo nhng ng dng dch t hc trong y t cng cng ti cc nc ang pht trin. Cun sch ny ch ra nhng cch thc c th ng dng dch t hc trong phng nga bnh tt v nng cao sc kho, nhm s dng cc ngun lc u t cho sc kho mt cch hiu qu nht v cng khuyn khch vic thc hnh lm sng tt khi n gii thiu kh chi tit nhng khi nim dch t hc ng dng trong lm sng. Cun sch gip sinh vin c th m t c nhng nguyn nhn gy bnh, t vong, chn thng v tn tt thng gp trong cng ng; vch ra nhng thit k nghin cu dch t ph hp v cc nh gi y vn c tnh ph phn Mt s nhn xt v phin bn u tin: y l cun sch hay nht v ch ny m ti tng cTi c bit gii thiu cun sch ny ti tt c cc gio vin dch t v cc sinh vin khp mi ni John Last, Ch bin cun t in Dch t hc Gio s danh d - Khoa dch t hc v Y t cng ng Trng i hc Ottawa, Canada c th trnh by c ht nhng l thuyt v ng dng ca dch t hc trong mt cun sch ngn gn l mt nhim v khng n gin, cun sch ny ca T chc Y t th gii thc s l mt thnh cng ng ca ngi Tp ch y khoa Vng quc Anh, S khc bit mi m, cng vi mt phng php v cch tip cn mi trong ging dy v hc tp mn dch tTi c bit gii thiu cun sch ti cc bn Tp ch nghin cu y khoa n Mt cun sch v dch t hc cn phi d c, d hiu, bao hm nhng thng tin c ngha, c th khuyn khch ngi c tip tc nghin cu mn hc ny v coi nh mt ti liu tham kho hu ch. Dch t hc c bn tho mn c tt c nhng yu cu ny v cn hn th na Tp ch ca Hi y khoa Thu in

Dch t hc c bn

Dch t hc c bn

Th vin T chc y t th gii Bonita, Ruth. Basic epidemiology / R. Bonita, R. Beaglehole, T. Kjellstrm. n phm ln hai. 1.Dch t hc. 2.Hng dn. I.Beaglehole, Robert. II.Kjellstrm, Tord. III.T chc Y t th gii. ISBN 92 4 154707 3 ISBN 978 92 4 154707 9 (Phn loi NLM: WA 105) T chc Y t th gii 2006 ng k bn quyn. C th nhn c cc n phm ca T chc Y t th gii t Trung tm bo ch ca T chc Y t th gii, 20 ng Appia, 1211 Geneva 27, Thy S (T.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Cc yu cu xin php in hoc dch cc n phm ca T chc Y t th gii cn gi ti Trung tm Bo ch T chc Y t th gii theo a ch trn (fax: +41 22 791 4806; e-mail: permissions@who.int). Th bc v cc ni dung trnh by trong n phm ny khng hm bt c kin no ca T chc Y t th gii v tnh trng lut php ca nc, lnh th, thnh ph, khu vc no hay c lin quan n phn nh bin gii hay ranh gii. ng k t trn bn l ng bin gii c lng c th cha c thng nht hon ton. Nhng ni dung lin quan n mt s cng ty hay nh sn xut c th khng hm l h c T chc y t th gii khuyn co hay hn nhng cng ty/nh sn xut khc khng c nhc n. Tr khi b li hoc b st, c th phn bit tn ca sn phm bng ch ci u tin l ch hoa. T chc y t th gii rt ch xc nhn nhng thng tin trong n phm ny. Tuy nhin, khng c bt c m bo no khi xut bn ti liu. Vic s dng v phin gii ty thuc vo trch nhim ca ngi c. T chc Y t th gii s khng chu trch nhim vi bt c tn tht no c th ny sinh do vic s dng n phm ny. In ti n .

Mc lc

iii

Mc lc
Li ni u...........................................................................................................1 Gii thiu .............................................................................................................1 Chng 1 Dch t hc l g? .........................................................................................1 Thng ip chnh.................................................................................................1 Bi cnh lch s ...................................................................................................1 Ngun gc ..............................................................................................1 Cc pht trin gn y ca dch t hc ..................................................1 nh ngha, phm vi v ng dng ca dch t hc..............................................3 nh ngha ..............................................................................................3 Phm vi...................................................................................................3 Dch t hc v y t cng cng .............................................................................5 Nguyn nhn gy bnh ..........................................................................5 Lch s t nhin ca bnh......................................................................5 Tnh trng sc khe ca qun th .........................................................6 nh gi can thip..................................................................................6 Thnh tu ca dch t hc...................................................................................7 u ma .................................................................................................7 Nhim c Methyl thy ngn..................................................................8 St thp tim v bnh tim.........................................................................9 Bnh thiu It .......................................................................................10 Ht thuc l, aming v ung th phi ..................................................10 V xng chu ....................................................................................11 HIV/AIDS ..............................................................................................12 SARS....................................................................................................13 Cu hi ..............................................................................................................13 Ti liu tham kho .............................................................................................14

iv

Mc lc

Chng 2 o lng sc khe v bnh tt...............................................................17 Thng ip chnh...............................................................................................17 nh ngha sc khe v bnh tt ......................................................................17 nh ngha ............................................................................................17 Tiu chun chn on..........................................................................17 o lng tn s bnh trng ..............................................................................19 Qun th nguy c .................................................................................19 Hin mc v mi mc...........................................................................19 T l cht mc ...................................................................................23 Mi lin quan gia cc o lng tn s bnh trng ............................24 S dng cc thng tin sn c o lng sc khe v bnh trng................25 T vong ................................................................................................25 Hn ch ca giy chng t ..................................................................25 Hn ch ca nhng h thng ghi nhn................................................25 Hng ti c lng c th so snh c.........................................26 T sut t vong..................................................................................................27 T vong s sinh ...................................................................................28 T sut t vong tr em .........................................................................29 T sut t vong m...............................................................................30 T sut t vong tui trng thnh........................................................30 Tui th trung bnh ...............................................................................30 T sut chun ha theo tui .................................................................31 Tnh trng bnh tt ............................................................................................33 Tn tt ..................................................................................................33 Cc yu t quyt nh, ch s sc khe v cc yu t nguy c ...........34 Cc o lng sc khe qun th tng hp khc ................................35 So snh s xut hin bnh ...............................................................................36 So snh tuyt i..................................................................................36 So snh tng i................................................................................37

Mc lc

Cu hi ..............................................................................................................38 Ti liu tham kho .............................................................................................39 Chng 3 Cc thit k nghin cu ............................................................................41 Thng ip chnh...............................................................................................41 Quan st v thc nghim ..................................................................................41 Cc nghin cu quan st .....................................................................42 Cc nghin cu thc nghim ...............................................................42 Dch t hc quan st..........................................................................................42 Cc nghin cu m t .........................................................................42 Nghin cu sinh thi ............................................................................43 Ngy bin sinh thi ...............................................................................45 Nghin cu ct ngang ..........................................................................45 Nghin cu bnh chng.......................................................................46 Nghin cu thun tp...........................................................................49 Tm tt cc nghin cu dch t ............................................................52 Dch t hc thc nghim ...................................................................................52 Th nghim phn b ngu nhin c i chng ...................................53 Th nghim thc a ............................................................................53 Th nghim cng ng ........................................................................54 Sai s tim tng trong cc nghin cu dch t hc ...........................................55 Sai s ngu nhin.................................................................................55 C mu.................................................................................................56 Sai s h thng.....................................................................................56 Sai lch do chn hay sai s chn.........................................................56 Sai s o lng ....................................................................................57 Nhiu .................................................................................................................58 Kim sot nhiu....................................................................................59 Tnh gi tr.............................................................................................60

vi

Mc lc

Vn o c ....................................................................................61 Cu hi ..............................................................................................................63 Ti liu tham kho .............................................................................................64 Chng 4 Cc thng k sinh hc c bn..................................................................67 Thng ip chnh...............................................................................................67 Tng hp s liu................................................................................................67 Cc bn v th..................................................................................68 th hnh bnh v th cu phn hnh ct nm ngang ...................69 Bn chm v bn t l ................................................................69 th hnh ct ......................................................................................70 th hnh dy .....................................................................................71 Phn b tn s v biu hnh ct......................................................71 Cc phn b chun ..............................................................................72 Tng hp cc s liu .........................................................................................72 Trung bnh, trung v v mode ...............................................................72 Phng sai, lch chun v sai s chun ........................................72 Cc khi nim c bn ca suy lun thng k ...................................................73 S dng cc mu suy lun ca qun th ........................................74 Khong tin cy......................................................................................74 Kim nh gi thuyt, gi tr p, lc thng k .........................................76 Gi tr p .................................................................................................76 Lc thng k.........................................................................................76 Cc phng php kim nh c bn.................................................................78 Kim nh t............................................................................................78 Kim nh Khi bnh phng cho bng cho.........................................79 Tng quan..........................................................................................79 Hi quy .................................................................................................80 Hi quy tuyn tnh.................................................................................81

Mc lc vii

Hi quy logic .........................................................................................82 Phn tch sng v m hnh hi quy Cox hazard ..................................83 ng cong Kaplan Meier ................................................................84 Cc vn c mu ..............................................................................85 Phn tch tng hp ............................................................................................86 Cu hi ..............................................................................................................87 Ti liu tham kho .............................................................................................88 Chng 5 Tnh nguyn nhn trong dch t hc........................................................89 Thng ip chnh...............................................................................................89 Khi nim v nguyn nhn................................................................................89 Nguyn nhn hay cn .....................................................................89 v cn .............................................................................................90 C ch gy bnh .................................................................................91 Nguyn nhn n l v a nguyn nhn .............................................91 Cc yu t ca nguyn nhn................................................................92 Tng tc.............................................................................................93 Trnh t/h thng cp bc ca cc nguyn nhn.................................94 Thit lp mi lin h nhn qu ..........................................................................95 Tiu ch nh gi cn nguyn .............................................................95 Mi quan h thi gian...........................................................................96 Tnh hp l ...........................................................................................96 Tnh nht qun .....................................................................................97 mnh ca s kt hp......................................................................99 Mi quan h liu - p ng ...............................................................100 Tnh thun nghch .............................................................................101 Thit kt nghin cu..........................................................................101 nh gi bng chng........................................................................102 Cu hi ..........................................................................................................103 Ti liu tham kho ..........................................................................................104

viii Mc lc Chng 6 Dch t hc v phng nga cc bnh khng ly nhim ....................107 Thng ip chnh............................................................................................107 Phm vi ca phng nga ...............................................................................107 Nhng khuynh hng hin ti ca t l t vong...............................107 Cc phng nga tim nng...............................................................109 Khung nguyn nhn ..........................................................................110 Cc cp phng bnh .................................................................................111 D phng cp 0 (d phng cn nguyn) .......................................................112 D phng cp I...............................................................................................114 Chin lc qun th ..........................................................................114 Chin lc c th nguy c cao .........................................................115 D phng cp II..............................................................................................117 D phng cp ba............................................................................................118 Sng tuyn .....................................................................................................119 nh ngha .........................................................................................119 Cc bin php sng tuyn.................................................................119 Cc tiu ch ca mt chng trnh sng tuyn .................................120 Cu hi ..........................................................................................................123 Ti liu tham kho ..........................................................................................124 Chng 7 Cc bnh truyn nhim: gim st dch t hc v phn hi ................127 Thng ip chnh............................................................................................127 Gii thiu ........................................................................................................127 nh ngha .........................................................................................127 Vai tr ca dch t hc.......................................................................127 Gnh nng bnh truyn nhim..........................................................128 Nh ng e d a t i s an ton c a con ng i v h th ng s c kh e ..................................................................................... 129 Dch v bnh lu hnh ...................................................................................130 Dch ...................................................................................................130

Mc lc

ix

Cc bnh lu hnh/a phng ........................................................132 Cc bnh truyn nhim mi xut hin v ti xut hin .....................133 Dy chuyn ly bnh .....................................................................................134 Tc nhn gy bnh truyn nhim......................................................135 Ly truyn..........................................................................................135 Vt ch ..............................................................................................136 Mi trng.........................................................................................137 iu tra v kim sot cc v dch bnh truyn nhim....................................137 iu tra ..............................................................................................137 Xc nh cc ca bnh .......................................................................137 Qun l v kim sot ........................................................................138 Gim st v thng bo .....................................................................139 Cu hi ...........................................................................................................142 Ti liu tham kho ..........................................................................................143 Chng 8 Dch t hc lm sng .............................................................................145 Thng ip chnh............................................................................................145 Gii thiu ........................................................................................................145 nh ngha s bnh thng v bt bnh thng ............................................145 Bnh thng l ph bin ...................................................................146 S bt thng kt hp vi bnh.......................................................147 Bt thng c th iu tr c ........................................................147 Cc xt nghim chn on ............................................................................148 Gi tr ca mt xt nghim ................................................................148 Lch s t nhin v tin lng .......................................................................149 Tin lng .........................................................................................150 Cht lng cuc sng .......................................................................150 S lng cuc sng ..........................................................................150 Hiu qu iu tr .............................................................................................151

Mc lc

S dng cc hng dn da trn bng chng .............................................152 D phng trong thc hnh lm sng .............................................................153 Gim cc yu t nguy c ..................................................................153 Gim cc yu t nguy c bnh nhn cc bnh xc nh..........154 Cu hi ..........................................................................................................155 Ti liu tham kho ..........................................................................................156 Chng 9 Dch t hc mi trng v ngh nghip...............................................157 Thng ip chnh............................................................................................157 Mi trng v sc khe .................................................................................157 Tc ng ca phi nhim vi cc yu t mi trng .......................158 nh gi cc bin php phng chng...............................................159 Phi nhim v liu lng ...............................................................................161 Khi nim chung................................................................................161 Gim st sinh hc..............................................................................163 Phin gii s liu sinh hc.................................................................163 o lng theo c th so vi theo nhm ...........................................164 Liu qun th ....................................................................................165 Cc quan h liu hu qu .............................................................166 Cc mi quan h liu p ng ......................................................167 nh gi nguy c ................................................................................... 167 nh gi nguy c ..............................................................................167 nh gi tc ng sc khe .............................................................167 Qun l nguy c ................................................................................167 nh gi tc ng sc khe mi trng...........................................168 Dch t hc chn thng ................................................................................169 Chn thng va chm giao thng.....................................................169 Chn thng ni lm vic .............................................................170 Bo lc ..............................................................................................171

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xi

T t ..................................................................................................171 Cc im c bit ca dch t hc mi trng v ngh nghip.....................171 Thit lp tiu chun an ton ..............................................................172 o lng phi nhim trong qu kh .................................................172 Tc ng cng nhn kh e m nh trong cc nghin c u ngh nghi p .................................................................................. 172 Nhng thch thc khng ngng i vi nhng nh dch t hc ......172 Cu hi ..........................................................................................................173 Ti liu tham kho ..........................................................................................174 Chng 10 Dch t hc, chnh sch y t v lp k hoch y t .............................177 Thng ip chnh............................................................................................177 Gii thiu ........................................................................................................177 Chnh sch y t..................................................................................177 Lp k hoch y t ..............................................................................177 nh gi ............................................................................................178 Chnh sch y t...............................................................................................178 nh hng ca dch t hc ...............................................................178 To khung chnh sch .......................................................................179 Chnh sch y t trong thc t ............................................................180 Xy dng k hoch v nh gi chm sc sc kho ....................................182 Chu trnh lp k hoch ...................................................................................182 nh gi gnh nng bnh tt ............................................................183 Tm hiu nguyn nhn.......................................................................185 o lng hiu qu can thip.............................................................186 nh gi hiu sut ............................................................................186 Trin khai can thip ...........................................................................188 Theo di can thip .............................................................................188 Cu hi ..........................................................................................................189 Ti liu tham kho ..........................................................................................190

xii Mc lc Chng 11 Cc bc u tin trong dch t hc thc hnh ...............................191 Thng ip chnh............................................................................................191 Gii thiu ........................................................................................................191 Cc bnh c th ...........................................................................................191 c c ph phn ............................................................................................192 Xy dng k hoch cho nghin cu ..............................................................195 La chn mt ti hay ch nghin cu.....................................196 Vit cng nghin cu.................................................................196 Tin hnh nghin cu .......................................................................197 Phn tch s liu ................................................................................198 Chun b ng ti ..............................................................................198 c thm ........................................................................................................198 Tip tc o to..............................................................................................200 Cu hi ..........................................................................................................201 Tm tt ..............................................................................................202 Phng php ...................................................................................202 Ph lc Tr li cu hi...................................................................................203

Mc lc xiii

Li ni u
Cun Dch t hc c bn ban u c vit nhm tng cng hc tp, o to v nghin cu trong lnh vc y t cng cng. K t khi cun sch c xut bn nm 1993, c hn 50.000 n phm c in, v c dch ra hn 25 ngn ng. Danh sch cc ngn ng c dch v a ch lin lc vi cc nh xut bn a phng c th yu cu ti Nh xut bn TCYTTG, T chc Y t th gii, 1211 Geneva 27, Thy S. Cun Dch t hc c bn bt u vi nh ngha dch t hc, gii thiu lch s dch t hc hin i, v a ra mt s v d v s dng v ng dng ca dch t hc. o lng nguy c v tnh trng bnh c gii thiu Chng 2 v Chng 3 bao gm cc ni dung tm tt v cc thit k nghin cu v nhng im mnh v hn ch ca chng. Phn gii thiu cc phng php thng k trong Chng 4 a ra nhng khi nim c bn v nhng cng c sn c phn tch s liu v nh gi tc ng ca can thip. Nhim v c bn ca nh dch t hc l hiu c qu trnh nh gi cn nguyn, v Chng 5 trnh by ni dung ny. ng dng ca dch t hc trong nhng lnh vc rng hn ca y t cng cng c trnh by trong nhng chng sau: bnh khng truyn nhim mn tnh (Chng 6), bnh truyn nhim (Chng 7), dch t hc lm sng (Chng 8) v Dch t hc mi trng, ngh nghip v chn thng (Chng 9); qu trnh lp k hoch y t c gii thiu trong Chng 10. Chng cui cng, Chng 11, trnh by nhng bc m nh dch t hc mi vo ngh c th thc hin hc tp cao hn v lit k mt s kt ni n cc kha hc hin ny v dch t v y t cng cng Cng tng t nh n phm u tin ca cun Dch t hc c bn, cc v d c ly t nhiu nc khc nhau minh ha cc khi nim dch t hc. iu ny khng c ngha y l tt c nhng v d v ton din, v chng ti khuyn khch hcvin v gio vin tm kim thm nhng vd ph hp ti a phng. Mi chng bt u vi mt s thng ip chnh v kt thc vi mt s cu hi ngn (cu tr li c cui sch) khuyn khch trao i v nh gi tin trnh. Cc tc gi cm n nhng ng gp ca John Last v Anthony McMichael cho n phm u tin.Martha Anker vit Chng 4 trong n phm u tin. Trong n phm th hai, Gio S O. Dale Williams vit Chng 4. Ti liu kha hc m chng ny da vo vit c ti trang http://statcourse.dopm.uab.edu. Mt s hiu nh cc phng trnh trong Chng 4 cng c a vo trong bn in ln hai ca n phm ny. Ngoi ra, cc tc gi cng xin cm n nhng ngi c ng gp cho n phm th hai ny bao gm: Michael Baker, Diarmid Campbell-Lendrum, Carlos Corvalen, Bob Cummings, Tevfik Dorak, Olivier Dupperex, Fiona Gore, Alec Irwin, Rodney Jackson, Mary Kay Kindhauser, Doris Ma Fat, Colin Mathers, Hoomen Momen, Neal Pearce, Rudolpho Saracci, Abha Saxena, Kate Strong, Kwok-Cho Tang, v Hanna Tolonen. Laragh Gollogly l qun l bin tp, v Sophie Guetanah-Aguettants v Christophe Grangier l nhng ngi thit k ha. Chng trnh quc t v An ton Ha hc (Chng trnh hp tc ca Chng trnh Mi trng Lin hp quc, T chc Lao ng Quc t, v T chc Y t th gii), C quan Pht trin Quc t Thy in (SIDA), C quan Hp tc nghin cu vi cc nc ang pht trin Thy in (SAREC) ng gp cho vic xy dng cun sch ny.

xiv Mc lc

Mc lc xv

Gii thiu
Vai tr c bn ca dch t hc l nng cao sc khe cng ng. Cun sch ny trnh by nhng nguyn l v phng php c bn ca dch t hc. Cun sch ny hng ti nhiu c gi, v c vit vi mc ch s dng lm ti liu ging dy cho cc chuyn gia trong lnh vc y t v mi trng. Mc ch ca cun sch ny l: Gii thch nhng nguyn l v nguyn nhn gy bnh trong c bit nhn mnh n nhng yu t mi trng c th thay i c; bao gm c nhng hnh vi chu tc ng ca mi trng, Khuyn khch vic ng dng dch t trong phng bnh v nng cao sc khe, Trang b cho nhng thnh vin ca cc chuyn ngnh lin quan n sc khe v dch v y t nhng kin thc gii quyt nhng vn sc khe cng ng v m bo nhng ngun lc y t c s dng vi hiu qu cao nht c th, v Khuyn khch nhng thc hnh lm sng tt bng cch gii thiu nhng khi nim v dch t hc lm sng.

Sau khi kt thc kha hc, hc vin c th nm c cc kin thc v: c im v ng dng ca dch t hc Cch tip cn dch t hc nh ngha v o lng s xut hin nhng tnh trng lin quan n sc khe trong qun th Nhng im mnh v hn ch ca cc thit k nghin cu dch t hc ng gp ca dch t hc phng bnh, nng cao sc khe v xy dng chnh sch y t ng gp ca dch t hc trong thc hnh lm sng Vai tr ca dch t hc trong nh gi hiu sut v hiu qu cc chng trnh chm sc y t.

Ngoi ra, hc vin cng c k vng c c mt s k nng, bao gm kh nng: M t c nhng nguyn nhn t vong, cc bnh v tn tt ph bin cng ng ca h a ra mt khung thit k nghin cu ph hp tr li nhng cu hi c th lin quan n nguyn nhn gy bnh, lch t t nhin, chn on, phng bnh v nh gi phng php iu tr v cc can thip khc phng v kim sot bnh.

Chng 1

Dch t hc l g?
Thng ip chnh

Dch t hc l khoa hc nn tng ca y t cng cng. Dch t hc c nhng ng gp ln vo vic ci thin sc kho cng ng. Dch t hc l cng c thit yu trong qu trnh xc nh v sp xp (mapping) cc bnh ni tri. Thng xuyn c tnh trng chm ch gia vic thu thp cc bng chng dch t hc v ng dng cc bng chng ny vo xy dng chnh snh y t.

Bi cnh lch s
Ngun gc
Dch t hc bt ngun t nhng quan st t thi Hypocrate hn 2000 nm trc y, cho rng cc yu t mi trng tc ng ln s xut hin bnh. Tuy nhin, cng phi n tn th k th mi chn mi c nhng o lng s phn b bnh tt trong cc nhm qun th ngi trn qui m ln. Giai on ny khng ch nh du s khi u chnh thc ca dch t hc m cn c c nhng thnh tu n tng nht ca chuyn ngnh ny.1 Mt v d ni ting l cc pht hin ca John Snow (Hp 1.1) cho thy nguy c ca bnh t thnh ph London c lin quan n vic ung nc ca cc cng ty cp khc nhau; bn (xem Hnh 4.1) lm ni bt im tp trung ca cc trng hp bnh. Cc nghin cu dch t ca Snow l mt trong s hng lot cc iu tra nh gi mi lin quan gia cc qu trnh vt l, ho hc, sinh hc, x hi hc v chnh tr.2 Vic so snh t l mc bnh trong cc nhm qun th ngi rt ph bin vo cui th k mi chn v u th k hai mi. Cch tip cn ny ban u c ng dng vo vic kim sot cc bnh truyn nhim (xem Chng 7), v cng c chng minh l mt phng php hiu qu m t mi lin kt gia cc iu kin hay tc nhn mi trng vi cc bnh c th. Vo na sau ca th k hai mi, c bit l cc nc c thu nhp cao hoc trung bnh, cch tip cn ny ny c p dng i vi cc bnh khng ly mn tnh nh bnh tim, ung th.

Cc pht trin gn y ca dch t hc

Dch t hc hin i l mt chuyn ngnh tng i mi v s dng cc phng php nh lng nghin cu bnh trong qun th ngi, vi nhng thng tin cho n lc phng nga v kim sot bnh tt. V d Richard Doll v Andrew Hill, t u nhng nm 1950, nghin cu mi lin quan gia ht thuc l v ung th phi. Nghin cu ca h c tin hnh trc cc nghin cu thc nghim v c tnh gy ung th ca nha thuc l v cc quan st lm sng cho thy mi lin quan gia ht

Chng 1

thuc l v cc yu t tim tng khc vi ung th phi. Qua vic s dng cc nghin cu thun tp di hn, h c kh nng thit lp s kt hp gia ht thuc l v ung th phi (Hnh 1.1).

Hp 1.1. Quan st sm ca dch t hc

John Snow xc nh v tr ngi nh ca tng ngi t vong do bnh t London vo giai on 184849 v 185354 v nhn thy mt s kt hp r rt gia ngun nc n vi cc trng hp t vong ny. ng so snh cc trng hp t vong ca cc qun c cc ngun cp nc khc nhau (Bng 1.1) v ch ra rng, cc qun do cng ty Southwark cp nc, s trng hp t vong v t l t vong u cao hn cc qun khc. Da trn nghin cu t m ca mnh, Snow xy dng c mt l thuyt v ng ly truyn ca bnh truyn nhim v gi rng bnh t lan truyn qua nc b nhim bn. ng khuyn khch vic nng cao cht lng nc cp trong mt khong thi gian di trc khi tm thy vi khun gy bnh t; nghin cu ca ng c tc ng trc tip v lu di i vi chnh sch cng cng. Nghin cu ca John Snow nhc nh chng ta rng cc bin php y t cng cng chng hn nh ci thin tnh trng cp nc sch v v sinh c nhng ng gp to ln vo vic tng cng sc kho cng ng v iu cn c th hin qua nhiu v d c th t nm 1850, cc nghin cu dch t hc c xc nh nh l cc bin php ph hp cn tin hnh. Tuy nhin, cng c th nhn thy rng, cc v dch t vn cn ph bin trong cc qun th ngho, c bit cc nc ang pht trin. Nm 2006, Angola bo co c 40.000 trng hp mc v 1600 trng hp t vong do t, Sudan bo co c 13.852 trng hp mc dn n 516 trng hp t vong ch trong vi thng u nm.

Nghin cu thun tp nhng bc s ngi Anh cho thy t l t vong gim mnh nhng ngi khng ht thuc trong nhiu thp k sau ny. Nhng bc s nam gii sinh ra vo giai on 19001930 m ht thuc, trung bnh t vong sm hn 10 nm so vi nhng ngi khng ht thuc5 (Hnh 1.2). Ht thuc l mt trng hp r rt, nhng i vi phn ln cc bnh, c th c nhiu yu t gp phn vo nguyn nhn gy bnh. Mt vi yu t ng vai tr thit yu dn n tnh trng bnh v mt vi yu t lm tng nguy c pht trin bnh. Cc phng php dch t hc mi c s dng phn tch cc mi lin quan ny. cc nc thu nhp thp v trung bnh, HIV/AIDS, lao v st rt l nhng nguyn nhn t vong ph bin, dch t hc cc bnh truyn nhim ng mt vai tr ht sc quan trng. Nhnh dch t hc ny ngy cng tr nn quan trng c bit nhng quc gia xut hin nhng bnh truyn nhim mi nh hi chng h hp cp tnh SARS, bnh b in (tn khoa hc l vim no th bt b Bovine Spongiform Encephalopathy BSE) hay i dch cm. Dch t hc pht trin mnh m trong vng 50 nm qua v th thch ln nht hin nay l tm hiu v hnh ng da trn cc yu t quyt nh sc kho v nhng bnh mang tnh x hi m phn ln cc yu t ny nm ngoi lnh vc y t.68 Bng 1.1. T vong do dch t cc qun ca London theo ngun nc do 2 cng ty cung cp, t 8/7 n 26/8/1854.
Cng ty cp nc Southwark Lambeth Dn s nm 1851 167.654 19.133 S t vong do t 884 18 T l t vong do t (trn 1000 dn) 5,0 0.9

Dch t hc l g

nh ngha, phm vi v ng dng ca dch t hc

nh ngha
Dch t hc c Last nh ngha l vic nghin cu s phn b v cc yu t quyt nh ca cc tnh trng hay s kin lin quan n sc kho trong cc qun th xc nh v vic ng dng nghin cu ny vo phng nga v kim sot cc vn sc kho (Xem Hp 1.2). Nh dch t hc khng ch quan tm ti t vong, bnh tt m cn c vi trng thi sc kho tt v quan trng nht l cc gii php tng cng sc kho. T bnh bao hm tt c s thay i khng mong mun ca tnh trng sc kho, bao gm c chn thng v sc kho tm thn. Hnh 1.1. T l t vong do ung th phi (trn 1000) trn s iu thuc4 ca cc bc s nam gii ngi Anh, nm 1951 1961.

Phm vi
Trng tm ca nghin cu dch t hc l qun th xc nh v a l hay cc kha cnh khc, v d mt n v nghin cu c th l mt nhm bnh nhn trong bnh vin hay cng nhn nh my. Mt qun th s dng trong dch t hc thng l qun th c chn t mt khu vc c th hay mt nc vo mt thi im c th. iu ny to c s cho vic xc nh cc nhm nh hn lin quan n gii, nhm tui, chng tc. Cu trc ca cc qun th khc nhau cc vng a l khc nhau v cc thi im khc nhau. Cc phn tch dch t hc phi tnh n s dao ng ny.

Chng 1

Hnh 1.2. T l sng sau tui 35 nhng bc s ngi Anh tip tc ht thuc v khng ht thuc sinh trong khong nm 19001930 ti tng thi im 10 nm mt5

Hp 1.2. nh ngha dch t hc9 T Dch t hc c ngun gc t ting Hylp, trong , t epi c ngha l trn, demos c ngha l qun th ngi v logos c ngha l nghin cu. nh ngha rng ny ca dch t hc c th c lm r hn nh sau : Thut ng Nghin cu Phn b Yu t quyt nh Gii thch Bao gm : gim st, quan st, kim nh gi thuyt, nghin cu phn tch v thc nghim cp n vic phn tch cc yu t : thi gian, con ngi, ni chn. Bao gm cc yu t nh hng ln sc kho nh sinh hc, ho hc, l hc, x hi, vn ho, kinh t, di truyn v hnh vi. Bao gm : bnh, cc nguyn nhn t vong, hnh vi nh ht thuc, cc trng thi sc kho tt, phn ng i vi cc ch d phng v vic cung cp v s dng dch v y t. Bao gm nhng ngi c cc c tnh c th phn bit c, chng hn nh cc nhm ngh nghip khc nhau. mc ch ca y t cng cng tng cng, bo v v phc hi sc kho.

S kin v tnh trng lin quan n sc kho

Cc qun th nh danh

ng dng vo vic phng v kim sot

Dch t hc l g

Dch t hc v y t cng cng

Y t cng cng, ni chung, cp n cc hnh ng mang tnh tp th nhm ci thin sc kho ca qun th.1 Dch t hc, mt trong cc cng c tng cng sc kho, c s dng theo nhiu cch khc nhau (Hnh 1.31.6). Cc nghin cu ban u trong lnh vc dch t hc thng quan tm n nguyn nhn (bnh cn) ca cc bnh truyn nhim v cng vic ny vn c ngha quan trng xc nh c cc bin php phng nga. Theo ngha ny, dch t hc l khoa hc y hc c bn vi mc ch ci thin sc kho qun th, c bit sc kho ca nhng qun th chu thit thi.

Nguyn nhn gy bnh

Mc d mt s bnh c nguyn nhn n thun l cc yu t di truyn, phn ln cc bnh c nguyn nhn l s tng tc gia cc yu t di truyn v mi trng. Tiu ng l mt v d ca mt bnh m nguyn nhn bao gm c hai yu t l di truyn v mi trng. Chng ta nh ngha khi nim mi trng mt cch rt rng, bao gm cc yu t sinh hc, ho hc, vt l, tm thn hay cc yu t vn ho c th tc ng ln sc kho (xem Chng 9). Hnh vi c nhn tc ng ln mi lin quan h ny v dch t hc c s dng nghin cu nh hng v tc ng ca can thip d phng thng qua tng cng sc kho (Hnh 1.3).

Lch s t nhin ca bnh

Dch t hc cng quan tm n qu trnh pht trin v hu qu bnh (lch s t nhin) cc cp c nhn v nhm (Hnh 1.4).

Hnh 1.3. Cn nguyn

Chng 1

Hnh 1.4. Lch s t nhin

Tnh trng sc kho ca qun th

Dch t hc thng c s dng m t tnh trng sc kho ca cc nhm qun th (Hnh 1.5). Hiu bit v gnh nng bnh tt trong qun th ng vai tr thit yu i vi cc nh lnh o y t, nhng ngi mong mun s dng ngun lc hn ch c th mang li hiu qu cao nht bng cch xc nh cc chng trnh sc kho u tin cho d phng v chm sc y t. Trong mt s lnh vc chuyn bit, v d dch t hc mi trng hay ngh nghip, dch t hc tp trung vo vic nghin cu nhng qun th c cc loi phi nhim c th.

Hnh 1.5. M t tnh trng sc kho qun th

nh gi can thip
Tc gi Archie Cochrane thuyt phc cc nh dch t hc nh gi hiu qu (effectiveness) v hiu sut (efficiency) ca cc dch v y t (Hnh 1.6).10 Vic ny c ngha l xc nh, v d nh tnh ph hp ca giai on nm vin do mt tnh trng no , gi tr ca vic iu tr bnh cao huyt p, hiu sut ca cc bin php v sinh nhm kim sot bnh truyn nhim v tc ng ca vic gim hm lng ch trong xng (xem Chng 10).

Dch t hc l g

Hnh 1.6. nh gi can thip

Vic p dng cc nguyn l v phng php dch t hc vo cc vn ang phi i mt trong thc hnh y hc dn n s pht trin ca dch t hc lm sng (xem Chng 8). Cng theo xu hng ny, dch t hc ang m rng sang cc lnh vc khc nh dch t hc dc hc, dch t hc phn t, v dch t hc di truyn (Hp 1.3).11 Hp 1.3. Dch t hc phn t v di truyn
Dch t hc phn t o lng phi nhim vi cc cht c th v cc p ng sinh hc sm thng qua: nh gi cc c tnh ca vt ch p ng vi nhng tc nhn bn ngoi S dng cc cht ch th sinh ha ca mt tnh trng c th nhm hiu chnh phn loi bnh. Dch t hc di truyn nghin cu cn nguyn, s phn b v kim sot bnh trong cc nhm c quan h h hng v cc nguyn nhn di truyn bnh trong qun th. Nghin cu dch t hc di truyn trong cc iu tra v gia nh hay qun th thit lp: Yu t di truyn gy bnh Quy m tc ng ca di truyn so vi cc yu t khc n nguy c xut hin bnh v Cc gien bnh Y t cng cng di truyn bao gm: Cc chng trnh sng lc ti cng ng T chc v nh gi cc dch v dnh cho cc bnh nhn c ri loi v di truyn v Tc ng ca di truyn ln thc hnh y hc.

Thnh tu ca dch t hc
u ma
Vic thanh ton bnh u ma trn th gii l mt thnh tu ln lao gp phn nng cao sc kho v hnh phc ca hng triu ngi, nht l nhng qun th ngho. u ma minh ha c thnh cng ln tht vng ca y t cng cng hin i. T nhng nm 1790 ngi ta bit rng nhim khun u b s gp phn bo v

Chng 1

chng virt u ma, tuy nhin phi mt gn 200 nm th li ch ca pht hin ny mi c chp nhn v p dng trn ton th gii. T chc Y t Th gii (TCYTTG) thc hin chin dch mnh m nhm loi b u ma trong nhiu nm. Dch t hc gi vai tr trung tm trong chin dch ny bng vic cung cp thng tin v phn b cc trng hp bnh, m hnh, c ch v mc lan truyn bnh, lp bn cc v dch bnh v nh gi cc bin php kim sot (Hp 1.4). S tht cho thy l khng c nhng trng hp vt ch l ng vt v s lng nhng trng hp nhim bnh th cp thp. Khi chng trnh thanh ton bnh u ma trong 10 nm do TCYTTG pht ng vo nm 1967, th mi nm c t 10 15 triu trng hp mi v 2 triu trng hp t vong 31 nc. S nc c cc trng hp bnh trong giai on 1967 1976 gim xung nhanh chng; n nm 1976 ch c 2 nc bo co c bnh u ma v trng hp xut hin bnh u ma t nhin cui cng c bo co trong nm 1977 mt ph n do phi nhim vi vius trong phng th nghim. Bnh u ma thng bo c thanh ton vo ngy 8 thng 5 nm 1980. C nhiu yu t gp phn vo thnh cng ca chng trnh: s cam kt chnh tr ton din, mc ch r rng, thi gian biu chnh xc, i ng cn b c o to tt v chin lc linh ng. Thm vo , bnh c nhiu c im to thun li cho vic thanh ton dt im nh s sn c vaccine phng bnh u ma. Nm 1979, TCYTTG duy tr mt kho d tr vaccine u ma tim chng cho 200 triu ngi. Kho d tr ny dn dn gim xung cn khong 2,5 triu liu. Nhng mi quan ngi hin nay v vn s dng v kh sinh hc khin TCYTTG tip tc duy tr v m bo lng d tr y vaccine trong trng hp cn thit.14 Hp 1.4. Cc c im dch t ca bnh u ma12
Cc phng php dch t hc c s dng thit lp cc c tnh sau y ca u ma: vt ch duy nht l ngi khng c vt trung chuyn c bnh cnh tin lm sng ngi khi bnh s min dch v khng c kh nng truyn bnh. u ma mc t t nhin khng ly truyn nhanh nh cc bnh truyn nhim khc nh si hay ho g. vic ly truyn bnh, ni chung thng qua tip xc lu di gia ngi vi ngi v phn ln bnh nhn nm lit ging khi mc bnh, chnh iu ny lm hn ch ly lan.

Nhim c Methyl thy ngn

Thy ngn l cht c t thi Trung C, gn y hn thy ngn tr thnh biu tng ca nhng mi him ho nhim mi trng. Trong nhng nm 1950, hp cht thu ngn c trong nc thi ca mt nh my Minamata, Nht Bn vo mt vnh nh (Hp 1.5). iu ny dn n s tch ly methyl thy ngn trong c gy ra nhim c trm trng cho ngi.15 y l mt v dch nhim c thu ngn t c u tin m ngi ta c bit v vic xc nh chnh xc nguyn nhn phi din ra trong vi nm. Bnh Minamata tr

Dch t hc l g

thnh mt trong nhng bnh do mi trng c chng minh tt nht bng t liu. V bng n dch th hai xy ra trong nhng nm 1960 mt khu vc khc ca Nht Bn. T n nay cc trng hp nhim c Methyl thu ngn nh hn do c cng c ghi nhn mt s nc.15, 16 Hp 1.5. Bnh Minamata
Dch t hc gi mt vai tr ch cht trong vic xc nh nguyn nhn v kim sot ca mt trong nhng v dch c bo co u tin gy ra bi nhim mi trng. Nhng trng hp u tin c cho l vim mng no do nhim khun. Tuy nhin ngi ta quan st thy rng 121 nn nhn ca bnh ny ch yu sng gn Vnh Minamata. iu tra tin hnh nhng ngi mc bnh v nhng ngi khng mc bnh cho thy cc nn nhn hu ht l cc thnh vin ca cc gia nh c ngh chnh l nh c. Nhng ngi n thm cc gia nh ny v cc thnh vin ca nhng gia nh n t c th khng mc bnh. V vy ngi ta i n kt lun rng c ci g trong c gy ng c cho ngi v bnh khng phi do ly truyn hay di truyn.

St thp tim v bnh thp tim

St thp tim v bnh thp tim c lin quan ti ngho i v c bit l iu kin nh ngho nn v cht chi, c hai yu t ny to iu kin thun li cho vic lan truyn cc nhim khun lin cu ng h hp trn. nhiu nc pht trin s trng hp mc bnh thp tim bt u gim t u th k hai mi, rt lu trc khi c thuc iu tr hu hiu nh sulonamides v penicillin (Hnh 1.7). Hnh 1.7. Ghi nhn v bnh st thp khp an Mch17

Ngy nay bnh gn nh khng cn xut hin cc nc pht trin, mc d cc bnh vi t l hin mc kh cao vn cn tn ti cc nhm ngi thit thi v kinh t v x hi. nhiu nc ang pht trin, bnh thp tim l mt trong nhng th ph bin nht ca bnh tim.

10 Chng 1 Dch t hc gp phn vo hiu bit ca chng ta v nguyn nhn ca st thp tim v bnh thp tim v vic pht trin cc bin php phng nga bnh thp tim. Cc nghin cu dch t hc cng nu bt vai tr ca cc yu t kinh t x hi gp phn gy nn cc v bng n st thp tim v s lan truyn ca nhim lin cu khun hng. R rng nguyn nhn gy cc bnh ny phc tp hn nguyn nhn gy nhim c Methyl thu ngn, bnh ch c mt nguyn nhn c hiu c nhn dng.

Bnh thiu It
Thiu it, xy ra ph bin mt s vng min ni, lm suy gim th lc v tinh thn c lin quan ti vic sn xut khng y lng it trong ni tit t tuyn gip.18 Bnh bu c v chng n n ln u tin c m t ch tit t khong 400 nm trc, ch khng phi n tn th k 20 ngi ta mi c y hiu bit cho php hnh thnh cc bin php d phng v kim sot c hiu qu bnh ny. Nm 1915, bu c lu hnh l bnh d dng phng trnh nht v vic s dng mui it khng ch bu c c xut trong nm ti Thy S.18 Mt thi gian ngn sau , cc cuc th nghim u tin trn quy m ln v it c tin hnh Akron, Ohio, M trn 5000 ph n t 11 n 18 tui. Cc kt qu d phng v iu tr rt kh quan v mui it c gii thiu trn quy m cng ng nhiu nc trong nm 1924. Vic s dng mui it c hiu qu v mui c dng quanh nm mc tng t nhau trong mi tng lp nhn dn. Thnh qu ph thuc vo vic sn xut v phn phi mui v i hi s tun th cc quy nh lut php, kim tra cht lng v nhn thc ca cng ng.

Hp 1.6. Bnh thiu it

Dch t hc gp phn vo vic xc nh v gii quyt vn thiu ht it; cc bin php d phng c hiu qu thch hp cho vic s dng mui it trn quy m ln, cng nh cc bin php gim st chng trnh it c lm r. Tuy nhin, c s chm tr khng cn thit trong vic ng dng nhng hiu bit ny lm gim au kh cho hng triu ngi cc nc ang pht trin m nn thiu it vn cn ph bin. Gn 1/3 tr n tui i hc trn ton th gii khng s dng lng it cn thit.19 S tin b ng k c thc hin trong thp nin cui cng vi vic khong 70% h gia nh c tip cn vi mui it so vi 2030% trong nm 1990.20

Ht thuc l, aming v ung th phi

Ung th phi tng c coi l mt bnh him gp, nhng t nhng nm 1930 c s gia tng t ngt s ung th phi, c bit cc nc cng nghip pht trin, u tin l nam gii. Gi y ngi ta r nguyn nhn chnh lm tng t l cht do ung th phi l ht thuc l. Nhng nghin cu dch t hc u tin tm hiu mi lin quan gia mc ung th phi c xut bn nm 1950. Nm nghin cu bnhchng cng b rng ht thuc l lin quan vi ung th phi nam gii. mnh ca mi lin quan ny trong nghin cu tin hnh nhng bc s ngi Anh (Hnh 1.1) l a ra cc bin php i ph mnh m v tc th, c bit, mi lin quan ny cng c khng nh trong cc nghin cu cc qun th khc nhau. Nu nh phng php tnh v phin gii t s chnh (odd ratio) c s dng trong nghin cu nhng bc s ngi Anh, th cc s liu Hnh 1.1 c th tnh ton nguy c tng i (relative risk) vi gi tr l 14 khi so nhng ngi ht thuc l vi nhng ngi

Dch t hc l g 11

khng ht, y l mt s kt hp rt mnh m kh c th bin gii l do sai s h thng mang li.21 Tuy nhin, c nhiu yu t phi nhim khc chng hn nh bi aming v nhim khng kh th cng gp phn lm tng gnh nng ung th. Hn th na, ht thuc l v phi nhim vi aming tng tc vi nhau, gy nn t l ung th phi cao hn nhng cng nhn va ht thuc va phi nhim vi bi aming (Bng 1.2) Bng 1.2. T l t vong do ung th phi chun ho theo tui (trn 100.000 dn) lin quan ti ht thuc l v phi nhim ngh nghip vi bi aming.22
Phi nhim vi aming Khng C Khng C Tin s ht thuc l Khng Khng C C T l t vong do ung th phi/100.000 dn 11 58 123 602

Cc nghin cu dch t hc c th gip lng ho nhng yu t mi trng gp phn vo qu trnh gy bnh. Khi nim v nguyn nhn c tho lun Chng 5.

V xng chu
Nghin cu dch t hc chn thng i hi s hp tc gia cc nh khoa hc trong lnh vc dch t hc, sc kho x hi v sc kho mi trng. Cc chn thng do ng, c bit gy c xng i (v xng chu) ngi cao tui, thu ht c s quan tm ln trong nhng nm gn y v nhng hu qu ca n lin quan nhiu n cc nhu cu chm sc sc kho cho ngi gi. Nguy c v xng chu tng theo cp ly tha ca tui v n l hu qu ca vic gia tng tht thot cht xng u xng i, tnh trng lin quan cht ch vi tui v vic gia tng tn xut ng cng lin quan vi tui. Cng vi vic gia tng s ngi gi trong qun th, s trng hp v xng chu s gia tng tng ng nu nh chng ta khng tin hnh cc bin php d phng. V v xng chu i hi thi gian nm vin lu, cc chi ph kinh t lin quan n v xng chu l ng k.23, 24 Trong nghin cu v chi ph do chn thng H Lan, v xng chu, xp hng th 14 theo t l mi mc trong 25 loi chn thng, nhng l loi chn thng c chi ph cao nht v chim ti 20% ca tng cc chi ph lin quan n chn thng. Phn ln cc trng hp v xng chu l do ng v hu ht cc trng hp t vong sau khi ng l hu qu ca cc bin chng v xng, c bit ngi cao tui.25 Cch gii quyt ti u phng v xng chu hin ti vn cha r rng. Dch t hc c vai tr rt quan trng khi xem xt cc yu t c th thay i v cc yu t khng th thay i nhm lm gim gnh nng ca v xng chu.

12 Chng 1

HIV/AIDS
Hi chng suy gim min dch mc phi (The acquired immunodeficiency syndrom AIDS) c xc nh u tin nh l mt thc th bnh ring bit vo nm 1981 ti Hoa K.26 Cho ti nm 1990, c tnh c khong 10 triu ngi b nhim virt HIV. T n nay c 25 triu ngi t vong v AIDS v thm 40 triu ngi b nhim virt HIV. S liu cho thy HIV/AIDS tr thnh mt trong cc bnh dch truyn nhim c sc ph hu gh gm nht c ghi nhn trong lch s (Hnh 1.8).28 Hnh 1.8. Dch AIDS trn ton cu 1990200328

Trong tng s 3,1 triu ngi t vong do AIDS trong nm 2005, gn 95% xy ra cc nc thu nhp thp v thu nhp trung bnh, vi 70% xy ra cc nc chu Phi khu vc cn Sahara v 20% cc nc chu . Mt b phn a s trong tng s t 4,3 ti 6,6 triu ngi mi nhim HIV trong nm 2005 sng nhng khu vc ny. Tuy nhin, cc khu vc hay cc nc ny, mc nhim bnh v ng ly rt khc nhau (Hp 1.7). Hp 1.7. Dch t hc v d phng HIV
Cc nghin cu dch t hc v x hi hc ng mt vai tr quan trng trong vic xc nh dch v phng thc ly truyn, xc nh cc yu t nguy c v cc yu t mang tnh x hi, v nh gi cc chng trnh can thip phng chng, iu tr v kim sot. Sng lc mu ca nhng ngi cho mu, tng cng tnh dc an ton, iu tr cc bnh ly truyn qua ng tnh dc khc, trnh s dng chung bm kim tim v phng ly truyn t m sang con bng thuc khng virt hin l nhng cch chnh kim sot ly truyn HIV/AIDS. Vi vic tm ra cc loi thuc khng virt mi v iu tr kt hp, cuc sng ca nhng ngi nhim HIV cc nc pht trin c ko di. Tuy nhin chi ph qu cao ca cc loi thuc ny, r rng hn ch vic s dng, v chng khng c a s nhng ngi nhim bnh s dng. Mt c gng quc t ln nhm tng cng c hi s dng thuc iu tr HIV/AIDS chin dch mang tn chin dch 3x5 (3 triu ngi c iu tr cho n cui nm 2005).25 t c con s l 1 triu ngi c iu tr v ngn nga c khong t 250.000 n 350.000 trng hp t vong. Mc ch mang tnh ton cu tip theo l nhm t c tip cn ton cu vi iu tr HIV trc 2010. Dch t hc c ng gp to ln vo hiu bit i dch AIDS; tuy nhin s hiu bit n thun khng m bo cho cc hnh ng d phng ph hp c trin khai.

Dch t hc l g 13

AIDS c thi gian bnh di; nu khng c iu tr, th khong mt na s ngi nhim virt gy suy gim min dch ngi (HIV) s tin trin thnh bnh AIDS trong khong 9 nm nhim (xem Chng 7). Virt c tm thy mt s cht dch c th, c bit l trong mu, tinh dch v dch m o. Vic ly nhim ch yu thng qua quan h tnh dc hoc dng chung kim tim b nhim virt. Virt cng c th c truyn qua khi truyn mu hoc cc sn phm mu b nhim virt, v t m b nhim sang con trong khi mang thai hay khi cho con b.

SARS
Mc d t vong hay gnh nng bnh tt l nh, v dch hi chng ng h hp cp (severe acute respiratory syndrome SARS) nhc nh th gii v mt mi nguy him chung l bnh truyn nhim. V dch cng lm ni bt tnh trng yu km ca cc dch v y t cng cng khng ch cc nc chu m cn c cc nc c thu nhp cao nh Canada. Hi chng SARS u tin xut hin vo thng 11 nm 2002 min nam Trung Quc vi 2 trng hp vim phi khng in hnh v khng r nguyn nhn. Vic ly truyn bnh c to iu kin thun li do nhng ngi bnh i li bng ng hng khng xy ra nhanh chng trong cc thng tip theo lm cho 8.000 ngi b mc bnh v khong 900 trng hp t vong 12 quc gia.31 T l t vong do SARS ly truyn cng ng thp hn do SARS ly truyn bnh vin, ni m cc cn b y t c tip xc gn v lin tc vi nhng ngi nhim bnh.30 Nhiu bi hc quan trng c rt ra t cc hot ng ng ph vi dch SARS. V d, SARS cho thy rng cc v dch tng t c th dn n hu qu kinh t v x hi vt xa tc ng ln sc kho.32 Tc ng ny ch ra tm quan trng ca mt bnh nghim trng mi trong mt th gii c s tng tc cht ch v bin i nhanh.

Cu hi
1.1. Bng 1.1 ch ra rng s ngi b t mt qun cao gp hn 40 ln mt qun khc. iu ny c phn nh nguy c mc t mi qun khng? 1.2. Lm th no kim nh thm vai tr ca ngun nc cp dn n t vong do t ? 1.3. V sao nghin cu trnh by Hnh 1.2 ch gii hn trong nhm i tng l bc s? 1.4. T Hnh 1.2 c th rt ra nhng kt lun g? 1.5. Nhng yu t no cn xt ti khi phin gii s phn b theo khu vc a l ca bnh? 1.6. c nhng thay i g xy ra i vi bnh st thp tim c bo co an Mch trong thi gian nu ra Hnh 1.7? iu g c th gii thch s thay i ny? 1.7. Bng 1.2 ni cho chng ta nhng iu g v s ng gp ca aming v ht thuc l i vi nguy c ung th phi?

14 Chng 1

Ti liu tham kho

1. Beaglehole R, Bonita R. Public health at the crossroads: achievements and prospects. Cambridge, Cambridge University Press, 2004. 2. Johansen PV, Brody H, Rachman S, Rip M. Cholera, Cholorform, and the Science of Medicine: a life of John Snow. Oxford, Oxford University Press, 2003 3. Snow J. On the mode of communication of cholera. London, Churchill,1855. (Reprinted in: Snow on cholera: a reprint of two papers. New York, Hafner Publishing Company, 1965). 4. Doll R, Hill A. Mortality in relation to smoking: ten years observations on British doctors. BMJ 1964;1:1399410. 5. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years observations on British doctors. BMJ 2004;328:151928. Medline doi:10.1136/bmj.38142.554479.AE 6. Lee JW. Public health is a social issue. Lancet 2005;365:10056. Medlinedoi:10.1016/S01406736(05)665415 7. Irwin A, Valentine N, Brown C, Loewenson, R, Solar O, et al. The Commission on Social Determinants of Health: Tackling the social roots of health inequities. PLoS Med 2006;3:e106. doi:10.1371/journal.pmed.0030106 8. Marmot M. Social determinants of health inequalities. Lancet 2005;365:1099 104. Medline 9. Last JM. A dictionary of epidemiology, 4th ed. Oxford, Oxford University Press, 2001. 10. Cochrane AL. Effectiveness and Efficiency. Random Reflections on Health Ser vices. London: Nuffield provincial Provinces Trust, 1972. (Reprinted in 1989 in association with the BMJ; reprinted in 1999 for Nuffield Trust by the Royal Society of Medicine Press, London. ISBN 185315394X). 11. Zimmern RL. Genetics in disease prevention. In: Puncheon D ed, Oxford Hand book of Public Health Practice. Oxford, Oxford University Press, 2001:544549. 12. Moore ZS, Seward JF, Lane M. Smallpox. Lancet 2006;367:42535. Medline doi:10.1016/S01406736(06)681439 13. Pennington Hnh Smallpox and bioterrorism. Bull World Health Organisation 2003;81:7627. Medline 14. Global smallpox vaccine reserve: report by the secretariat. Geneva, World Health Organization, 2004. http://www.who.int/gb/ebwha/pdf_files/EB 115/B115_36_en.pdf 15. McCurry J. Japan remembers Minamata. Lancet 2006;367:99100. Medline doi:10.1016/S01406736(06)679440 16. Methylmercury (Environmental health criteria, No 101). Geneva, World Health Organization, 1990. 17. Taranta A, Markowitz M. Rheumatic fever: a guide to its recognition, preven tion and cure, 2nd ed. Lancaster, Kluwer Academic Publishers, 1989. 18. Hetzel BS. From Papua to New Guinea to the United Nations: the prevention of mental defect due to iodine deficiency disease. Aust J Public Health 1995;19:2314. Medline 19. De Benoist B, Andersson M, Egli I et al., eds. Iodine status: worldwide WHO data base on iodine deficiency. Geneva, World Health Organization, 2004. 20. Hetzel BS. Towards the global elimination of brain damage due to iodine deficiency the role of the International Council for Control of Iodine Deficiency Disorders. Int J Epidemiol 2005;34:7624. Medline doi:10.1093/ije/dyi073 21. Thun MJ. When truth is unwelcome: the first reports on smoking and lung cancer. Bull World Health Organ 2005;83:14453. Medline

Dch t hc l g 15

22. Hammond EC, Selikoff IJ, Seidman Hnh Asbestos exposure, cigarette smoking and death rates. Ann N Y Acad Sci 1979;330:47390. 23. Meerding WJ, Mulder S, van Beeck EF. Incidence and costs of injuries in the Netherlands. Eur J Public Health 2006;16:27278. 24. Johnell O. The socioeconomic burden of fractures: today and in the 21st cen tury. [Medline]. Am J Med 1997;103:S2026. Medline doi:10.1016/S0002 9343(97)900231 25. Cumming RG, Nevitt MC, Cummings SR. Epidemiology of hip fractures. Epi demiol Rev 1997;19:24457. 26. Gottlieb MS, Schroff R, Schanker HM, Weisman JD, Fan PT, Wolf RA, et al. Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency. N Engl J Med 1981;305:142531. Medline 27. 2004 Report on the global AIDS epidemic: 4th global report. Geneva, Joint United Nations Programme on HIV/AIDS, 2004 28. AIDS Epidemic Update: December, 2005. Geneva, UNAIDS/WHO, 2005. 29. Jongwook L. Global health improvement and WHO: shaping the future. Lancet 2003;362:20838. Medline doi:10.1016/S01406736(03)151070 30. SARS. How a global epidemic was stopped. Manila, WHO Regional Office for the Western Pacific, 2006. 31. Wang MD, Jolly AM. Changing virulence of the SARS virt: the epidemiological evidence. Bull World Health Organ 2004;82:5478. Medline 32. Assessing the impact and costs of SARS in developing Asia. Asian development outlook update 2003. Asian Development Bank, 2003. http://www.adb.org/ Documents/Books/ADO/2003/update/sars.pdf.

17

Chng 2

o lng sc khe v bnh tt

Thng ip chnh
Vic o lng sc kho v bnh tt l thc hnh c bn trong dch t hc. C nhiu loi o lng m t tnh hnh sc kho ca qun th. Tnh trng sc kho ca qun th khng c o lng y nhiu ni trn th gii, v s thiu thng tin ny l mt thch thc ln i vi cc nh dch t hc.

nh ngha sc kho v bnh tt

nh ngha
nh ngha hon chnh nht v sc kho l nh ngha do T chc y t th gii (TCYTTG) xut nm 1948 nguyn vn l: Sc kho l mt tnh trng hon ton thoi mi v th cht, tinh thn, x hi ch khng ch n thun l khng c bnh hay tn tt.1 nh ngha ny vn l hp l nht, d b ph bnh do vic kh xc nh v o lng s thoi mi. Nm 1977, Hi ng Y t Th gii ra quyt tm n nm 2000 tt c mi ngi u c th duy tr sc kho cho php h sng mt cuc sng c hiu qu v kinh t cng nh x hi. Cam kt v chin lc Sc kho cho mi ngi ny c i mi vo nm 1998 v tip tc sau vo nm 2003.2 Dch t hc cn n nhng nh ngha thc t v sc kho v bnh tt, tp trung vo nhng kha cnh sc khe d dng o lng c v c th ci thin. Nhng nh ngha v tnh trng sc kho ca cc nh dch t hc thng n gin, nh c bnh hay khng c bnh (xem Hp 2.1). Vic xy dng cc tiu chun xc lp s hin din ca mt bnh i hi phi c nh ngha v tnh trng bnh thng v bt bnh thng. Tuy nhin thng kh xc nh th no l bnh thng v him khi c s phn bit r rng gia bnh thng v bt bnh thng, c bit i vi nhng bin lin tc c dng phn b chun lin quan n mt s loi bnh. (Xem Chng 8). V d, qui nh v im gii hn cho iu tr cao huyt p thay i tu theo trng hp, do u c s gia tng lin tc v nguy c bnh tim mch cc mc (xem Chng 6). Mt im gii hn xc nh cho mt trng hp bt thng c da vo nh ngha p dng c ch khng phi mt ngng xc nh no. Cng tng t nh vy i vi cc tiu ch xc nh phi nhim c nguy c cho sc kho: v d, qui nh mc ch trong mu an ton phi da vo nhng bng chng sn c, v c th thay i theo thi gian (Xem Chng 9).

Tiu chun chn on

Tiu chun chn on thng da trn cc triu chng, biu hin, tin s v kt qu xt nghim. V d: vim gan c th c xc nh khi c s hin din khng th trong mu; bnh bi phi aming c nhn bit khi c cc triu chng v biu hin v nhng bin i chc nng phi c th, cc du hiu X quang v x ha hoc dy ha mng phi v tin s phi nhim vi si aming. Bng 2.1 cho thy chn on st

18 Chng 2 thp khp c th da trn mt s biu hin ca bnh, trong mt s biu hin c nh gi quan trng hn nhng biu hin khc. Trong mt s trng hp, nhng tiu ch rt n gin cng c th c s dng. V d, t sut t vong do vim phi tr em cc nc ang pht trin gim xung ph thuc vo vic pht hin v cha tr nhanh chng. Hng dn qun l bnh ca T chc Y t Th gii khuyn co rng cc trng hp vim phi c th pht hin da vo triu chng lm sng, m khng cn n vic khm bng ng nghe, X quang ngc hay cc xt nghim. Dng c cn n duy nht l ng h theo di nhp h hp. Vic s dng khng sinh i vi nhng tr nghi ng vim phi, ch da vo vic khm c th, c khuyn co nhng ni c t l vim phi cao, v nhng ni khng c ngun lc chn on nhng nguyn nhn khc.5 Tng t nh vy, nh ngha lm sng ca AIDS ngi trng thnh c xy dng t nm 1985, s dng nhng ni thiu ngun lc chn on.6 nh ngha trng hp bnh ca TCYTTG cho h thng gim st AIDS ch cn hai biu hin chnh (st cn 10% tng cn nng, tiu chy mn tnh, hoc st ko di) v mt biu hin nh (ho lin tc, mn gip, vim hch bch huyt lan rng, v.v). Nm 1993, Trung tm Kim sot bnh nh ngha AIDS l bao gm tt c nhng ngi c hm lng t bo bch huyt T CD4+ nh hn 200 trn 1 micro lt.7 Hp 2.1. nh ngha trng hp bnh
Bt c nh ngha no c s dng trong dch t hc, nh ngha phi r rng, trong nhiu hon cnh khc nhau v nhiu ngi khc nhau d s dng v o lng c bng phng php chun. Mt nh ngha r rng v ngn gn i vi mt bnh s m bo cng mt thc th nhm hay c nhn khc nhau ang c o lng. nh ngha c thc hnh trong lm sng thng t cng nhc hn v thng b nh hng bi phn on lm sng, mt phn l do ta c th tin hnh nhiu xt nghm nhiu bc cho n khi chn on c khng nh.

Bng 2.1. Tiu chun Jones hng dn chn on st thp khp (tiu ch Jones, 1992)4
Xc sut st thp khp c th c xc nh bi s hin din ca 2 tiu chun chnh hay 1 tiu chun chnh v 2 tiu chun ph, nu c thm bng chng ca s nhim lin cu khun nhm A trc a Cc tiu chun chnh Vim tim Vim a khp Ma vn Ban c b Cc ht di da Cc tiu chun ph Lm sng au khp St Xt nghim Phn ng giai on cp tnh tng cao: Tc huyt trm Protein C phn ng Khong P R ko di

Bng chng v nhim lin cu khun nhm A trc : S lng vi khun hng hoc xt nghim nhanh khng nguyn lin cu khun chun khng th lin cu khun tng cao

o lng sc khe v bnh tt 19

Tiu chun chn on c th thay i rt nhanh do kin thc ngy cng nhiu hoc cc k thut chn on c ci tin; tiu chun cng thng thay i ty theo hon cnh thc t. Chng hn tiu chun ban u ca TCYTTG v nhi mu c tim s dng trong cc nghin cu dch t hc c thay i t khi c phng php khch quan nh gi in tm (m Minnesota) vo nhng nm 1980.8, 9 Cc tiu chun sau c chnh sa vo nhng nm 1990, khi c th o lng cc enzyme tim.10

o lng tn s bnh trng

Mt s o lng tn s bnh trng da vo khi nim v hin mc v mi mc. Tuy nhin, cc nh dch t hc vn cha thng nht c khi nim ca cc thut ng trong lnh vc ny. Trong ti liu ny, chng ti ch yu s dng nhng nh ngha trong cun T in dch t hc ca Last.11

Qun th nguy c
Yu t quan trng tnh ton cc o lng tn s bnh trng l c lng chnh xc s ngi ang tin hnh nghin cu. L tng l cc con s ny ch bao gm nhng ngi c nguy c mc bnh ang c nghin cu. Chng hn, nam gii khng th c tnh n khi c lng tn s ung th c t cung (Hnh 2.1). Hnh 2.1. Qun th nguy c trong nghin cu ung th c t cung

Tt c nhng ngi c kh nng b mc mt bnh c gi l qun th nguy c, v c th c nh ngha trn c s cc yu t nhn khu, a l hay mi trng. V d, cc chn thng ngh nghip ch xy ra nhng ngi ang lm vic, v vy qun th nguy c l lc lng lao ng; mt s nc, bnh brucellosis (bnh do vi khun, c bit gy ra cho tru b) ch xy ra nhng ngi tip xc vi sc vt b nhim khun, do qun th nguy c bao gm nhng ngi lm vic trong cc trang tri v cc l m.

Hin mc v mi mc
T sut mi mc ca mt bnh l tc xut hin cc trng hp bnh mi trong mt khong thi gian mt qun th xc nh, trong khi t l hin mc l s trng hp ang c bnh mt qun th xc nh trong mt khong thi gian hay mt thi im. C nhng im khc nhau c bn xc nh s xut hin (xem Bng 2.2) v mi lin

20 Chng 2 h gia hin mc v mi mc thay i ty theo tng bnh. C nhng bnh c t l mi mc thp nhng t l hin mc cao nh bnh tiu ng hay c nhng bnh c t l mi mc cao nhng t l hin mc thp nh bnh ho thng thng. Ho thng thng xy ra nhiu hn so vi bnh tiu ng nhng ch ko di trong mt khong thi gian ngn, trong khi tiu ng l ko di c cuc i. Bng 2.2. S khc bit gia hin mc v mi mc
Mi mc T s Mu s Trng tm S trng hp bnh mi trong mt khong thi gian xc nh Qun th nguy c Trng hp bnh l mi hay c Thi im bnh xut hin Hin mc S trng hp ang mc bnh vo mt thi im Qun th nguy c S c tn ti hay khng tn ti ca bnh Khong thi gian l tu , thay v mt khonh khc thi gian c lng xc sut ca qun th ang mc bnh trong khong thi gian nghin cu Hu ch trong nghin cu gnh nng ca cc bnh mn tnh v l c s cho dch v y t

S dng

Th hin nguy c nhim bnh L o lng chnh ca nhng bnh hoc tnh trng cp tnh, nhng cng c s dng cho c nhng bnh mn tnh Hu ch hn cho nhng nghin cu xc nh nguyn nhn

Lu : Nu trng hp mi mc khng c cha khi, v tip tc theo thi gian, trng hp s tr thnh trng hp ang mc (hin mc). Khi , hin mc = mi mc x thi gian ko di ca bnh Vic o lng mi mc v hin mc lin quan n vic m s trng hp bnh trong mt qun th nguy c xc nh. Ghi nhn s trng hp bnh m khng cp n qun th nguy c cho thy qui m tng th ca vn sc khe hay xu hng ngn hn trong mt qun th, nh trong mt v dch. Bo co Dch t hng tun (Weekly Epidemiological Record) ca TCYTTG bao gm cc s liu mi mc ca bnh di dng s trng hp bnh, mc d bn cht l s liu th, nhng vn c th cung cp thng tin hu ch v s pht trin ca cc dch bnh truyn nhim. Thut ng T l tn cng thng c dng thay cho t l mi mc trong mt v bng pht dch bnh mt qun th hp trong mt khong thi gian ngn. T l tn cng c th c tnh bng s ngi nhim bnh chia cho s ngi c phi nhim. V d, trong trng hp v dch ng c thc phm, t l tn cng c th c tnh cho tng loi thc n n, v sau so snh cc t l ny vi nhau xc nh ngun ly nhim. S liu mi mc v hin mc s tr nn hu ch hn nu c chuyn thnh t sut (xem Bng 1.1). Mt t sut c tnh bng cch chia s trng hp bnh cho tng s ngi tng ng trong qun th nguy c; v c biu hin bng s trng hp trn 10n ngi. Mt s nh dch t hc ch s dng thut ng t sut cho nhng o lng tn s bnh trng theo n v thi gian (tun, nm, v.v). Ngoi ra trong cun sch ny, chng ti s dng thut ng bnh theo ngha rng hn, bao gm nhng bnh lm sng, nhng bin i sinh ha v sinh l, chn thng v bnh tm thn.

o lng sc khe v bnh tt 21

Hin mc (prevalence)
T l hin mc (P) mt bnh c tnh theo cng thc sau:
P = S trng hp c bnh hay mt tnh trng trong mt thi im hay mt khong thi gian S ngi trong qun th nguy c ti thi im

(x 10n)

S liu v qun th nguy c khng phi bao gi cng c sn v trong nhiu nghin cu, th tng dn s trong a bn nghin cu c s dng nh mt s gn ng ca qun th nguy c. T l hin mc thng c biu din di dng s trng hp bnh trn 100 (phn trm) hay trn 1000 ngi. P s nhn vi mt ly tha thch hp: 10n. Nu s liu c thu thp vo mt thi im, th P c gi l t l hin mc im. Trong mt s trng hp s ph hp hn nu s dng t l hin mc k, c tnh bng cch ly tng s trng hp c bnh trong mt khong thi gian xc nh, chia cho tng qun th nguy c ti im gia ca khong thi gian. Tng t nh vy, t l hin mc c i l tng s ngi c bit l tng mc bnh trong t nht mt s khong thi gian ca cuc i. Ngoi tui tc, mt s yu t quyt nh t l hin mc (Hnh 2.2). C th l: Mc trm trng ca bnh (nu nhiu ngi mc bnh m t vong th t l hin mc ca bnh s gim); Khong thi gian b bnh (nu bnh ko di trong khong thi gian ngn hn th t l hin mc bnh s thp hn nu bnh ko di trong khong thi gian di hn); S trng hp mi mc bnh (nu nhiu ngi mi mc bnh th t l hin mc bnh s cao hn nu c t ngi mi mc bnh hn). Bng tm tt cc yu t nh hng ti t l hin mc bnh c trnh by trong Hnh 2.2 Hnh 2.2. Cc yu t nh hng n t l hin mc

V t l hin mc chu nh hng ca rt nhiu yu t khng lin quan ti nguyn nhn ca bnh, nn cc nghin cu v tnh trng hin mc thng khng cho thy nhng bng chng r rt v nguyn nhn. Tuy nhin, cc o lng hin mc rt hu ch trong vic nh gi nhu cu v cc bin php d phng v lp k hoch cho cc dch v y t. T l hin mc thng hu ch trong vic o lng s xut hin cc tnh trng c s tin trin t t, nh qu trnh tin trin ca bnh tiu ng hay thp tim. T l hin mc bnh tiu ng tp 2 c o lng nhiu qun th khc nhau theo nhng tiu ch ca TCYTTG (xem Bng 2.3); khong dao ng ln cho thy tm quan

22 Chng 2 trng ca nhng yu t x hi v mi trng trong vic gy bnh, v cho thy nhng nhu cu khc nhau v dch v y t cho bnh tiu ng ti nhng qun th khc nhau.

Bng 2.3. T l hin mc bnh tiu ng tp 2 hiu chnh theo tui mt s qun th (3064 tui)12
Nhm dn tc/nhm nh Ngi gc Trung quc Trung quc Mauritius Singapore n Fiji Nng thn Thnh th Nam n Nng thn Thnh th Singapore Sri Lanka T l hin mc hiu chnh theo tui (%) Nam N 1.6 16.0 6.9 23.0 16.0 3.7 11.8 22.7 5.1 0.8 10.3 7.8 16.0 20.0 1.7 11.2 10.4 2.4

Mi mc
T sut mi mc cho bit tc xut hin nhng trng hp mi mc bnh xy ra trong mt qun th. o lng mi mc tnh n nhng khong thi gian m trong nhng c nhn khng c bnh, v v th, c nguy c pht trin bnh. Khi tnh t sut mi mc, t s l s trng hp mi mc trong mt khong thi gian xc nh v mu s l qun th c nguy c mc bnh trong cng thi gian. Cch tnh t sut mi mc chnh xc nht l tnh o lng mi mc theo ngi thi gian.11 Mi mt ngi trong qun th nghin cu ng gp mt ngi nm vo mu s cho mi nm (hoc ngy, tun, thng) theo di trc khi bnh pht trin hay i tng khng c theo di na. T sut mi mc (I) c tnh nh sau:
I = S ngi mi mc bnh trong mt khong thi gian xc nh S ngi c phi nhim vi nguy c trong cng khong thi gian nghin cu (x 10n)

T s ch l nhng trng hp ln u tin mc bnh. n v ca t sut mi mc phi lun c n v thi gian (s trng hp trn 10n v trn ngy, thng, hay nm ) i vi mi c th trong qun th, thi gian quan st l thi gian m i tng cha b mc bnh. Mu s tnh t sut mi mc v th l tng s ngi thi gian trong khong thi gian quan st ca qun th nguy c. V khng th o lng mt cch chnh xc khong thi gian khng mc bnh, mu s ca t sut mi mc thng c c lng bng cch nhn kch thc trung bnh ca qun th vi khong thi gian nghin cu. Cch tnh ny c chnh xc chp nhn c khi kch thc qun th l ln v n nh v t sut mi mc thp, nh vi tnh trng t qu. Trong mt nghin cu M, t sut mi mc t qu c tnh trn 118.539 ph n tui t 30 55 v cha b bnh mch vnh, t qu v ung th trong nm 1976 (xem Bng 2.4).

o lng sc khe v bnh tt 23

Ngi ta ghi nhn c 274 trng hp t qu trong 8 nm theo di (tng s 908.447 ngi nm). T sut mi mc t qu chung l 30,2 trn 100.000 ngi nm quan st, t sut ny cao hn nhng ngi ht thuc so vi nhng ngi khng ht thuc; ngi tng ht thuc th c t sut nm gia 2 nhm ht thuc v khng ht thuc. Bng 2.4. Mi lin quan gia t sut mi mc t qu mt nhm thun tp gm 118 539 ph n 13
Tnh trng ht thuc Cha bao gi ht tng ht Hin ang ht Tng s S trng hp t qu 70 65 139 274 S nginm quan st (trong 8 nm) 395 594 232 712 280 141 908 447 T sut mi mc (trn 100 000 ngi nm) 17,7 27,9 49,6 30,2

T l mi mc tnh ly (CI)
T l mi mc tch ly l o lng n gin hn v s xut hin bnh hay mt tnh trng sc kho. Khng ging nh t sut mi mc, t l ny ly mu s ti thi im bt u nghin cu. T l mi mc tnh ly (CI) c tnh nh sau:
CI = S ngi mi mc bnh trong mt khong thi gian xc nh S ngi khng b bnh trong qun th nguy c khi bt u nghin cu (x 10n)

T l mi mc tch lu (CI) thng c biu din di dng s trng hp mi mc trn 1.000 ngi. Bng 2.4 cho thy t l mi mc tch lu t qu trong 8 nm theo di l 2,3/1.000 (274 trng hp t qu chia cho 118.539 ph n tham gia nghin cu). V mt thng k th CI l xc sut hay nguy c m cc c th trong qun th pht trin bnh trong mt khong thi gian xc nh. Khong thi gian c th di bt k nhng thng l mt vi nm, hoc thm ch c th l c cuc i. T l mi mc tch lu v vy cng tng t nh khi nim nguy c t vong c dng trong cc tnh ton sinh t v bng sng. S n gin ca t l mi mc tch ly gip t l ny d dng truyn ti c thng tin v sc khe n qun chng ni chung.

T l cht-mc
T l cht mc l mt o lng v mc trm trng ca mt bnh v c nh ngha l t l ca nhng trng hp mc mt bnh hay mt tnh trng sc kho no b t vong trong mt khong thi gian xc nh. T l ny thng c biu din di dng phn trm.
S trng hp t vong v mt bnh trong mt khong thi gian xc nh S trng hp c chn on l mc bnh trong cng thi gian

T l cht mc (%)

x 100

24 Chng 2

Mi lin quan gia cc o lng tn s bnh trng

o lng hin mc ph thuc vo c o lng mi mc v khong thi gian mc bnh. Vi iu kin t l hin mc (P) thp v khng thay i nhiu theo thi gian th P c th c c lng nh sau: P = T sut mi mc x Khong thi gian mc bnh trung bnh T l mi mc tch lu ca mt bnh ph thuc c vo t sut mi mc v khong thi gian nghin cu. V t sut mi mc thng thay i theo tui, cho nn t sut mi mc theo tui cn c cn nhc tnh. T l mi mc ly tch l mt c lng gn ng hu ch ca t sut mi mc khi t sut mi mc thp v khong thi gian nghin cu ngn. Hnh 2.3 minh ha nhiu o lng tn s bnh trng khc nhau. V d ny m t nghin cu theo di by ngi trong vng 7 nm. Hnh 2.3. V d v tnh ton s xut hin ca bnh

Hnh 2.3 cho thy: T sut mi mc bnh trong thi gian 7 nm c tnh bng s trng hp mi mc (3) chia cho tng s thi gian c nguy c mc bnh ca qun th (33 ngi nm), ngha l 9,1 trng hp trn 100 ngi nm; T l mi mc tch ly c tnh bng s trng hp mi mc trong qun th nghin cu (3) chia cho s ngi khng c bnh vo lc bt u nghin cu (7), tng ng vi 43 trng hp/100 ngi trong 7 nm; Thi gian mc bnh trung bnh bng tng s nm mc bnh chia cho tng s trng hp mi mc bnh, hay 10/3 = 3,3 nm; T l hin mc ph thuc vo thi im bt u nghin cu; v d, vo u nm th 4, t l hin mc tnh bng t s ca s ngi c bnh (2) trn s

o lng sc khe v bnh tt 25

ngi trong qun th quan st c ti thi im (6), tng ng vi 33 trng hp/100 ngi. Cng thc tnh t l hin mc trn c th c lng t l hin mc trung bnh l 30 trng hp/100 (9,1 x 3,3); T l chtmc l 33%, ngha l 1 trng hp t vong trong s 3 trng hp mc bnh.

S dng cc thng tin sn c o lng sc khe v bnh trng

T vong
Hp 2.2. Phn loi quc t v bnh tt (ICD)
ICD-10 bt u c s dng nm 1992 v l phn loi mi nht trong tp hp cc phn loi c t nhng nm 1850. ICD tr thnh phn loi chn on tiu chun cho tt c cc mc ch dch t cng nh qun l y t. ICD-10 c s dng phn loi bnh tt v nhng vn sc kho khc c ghi nhn trong nhiu loi h s, bao gm c giy chng t v biu ca bnh vin. Cch phn loi ny gip cho cc quc gia c th lu tr v khi phc thng tin chn on cho mc ch lm sng v dch t, v bin son cc thng k t vong v bnh tt quc gia.

Cc nh dch t hc thng bt u iu tra v tnh trng sc kho ca mt qun th bng nhng thng tin nh k thu thp c. nhiu nc thu nhp cao, cc s liu v nguyn nhn t vong c ghi nhn trong giy chng t, trong bao gm cc thng tin v tui, gii, ngy sinh v ni . Ti liu Phn loi thng k quc t v bnh v cc vn sc kho lin quan (ICD) a ra hng dn phn loi t vong.14 Cc quy trnh phn loi c b sung nh k tnh n s xut hin ca nhng bnh mi v thay i trong nh ngha trng hp bnh, v c dng m ho cc nguyn nhn t vong (xem Hp 2.2). Phn loi bnh tt quc t c chnh sa n ln th 10, v vy c gi l ICD10.

Hn ch ca giy chng t
S liu c c t thng k t vong c kh nng b nhiu sai st khc nhau, nhng nhn t kha cnh dch t hc, th nhng s liu ny cung cp nhng thng tin v gi v cc xu hng tnh trng sc kho ca qun th. Tnh hu dng ca s liu ph thuc vo nhiu yu t, bao gm mc y ca h s v chnh xc trong vic xc nh nguyn nhn t vong, c bit nhng ngi cao tui, nhm c t l c khm nghim t thi thp. Cc nh dch t hc ph thuc rt nhiu vo s liu thng k t vong nh gi gnh nng bnh tt, cng nh theo di cc thay i v bnh tt qua thi gian. Tuy nhin, mt s nc, khng c sn cc thng k c bn v tnh trng t vong, thng l do thiu ngun lc thit lp h thng bo co sinh t thng xuyn. i vi cc dch v y t, vic cung cp cc thng tin chnh xc v nguyn nhn t vong c coi l u tin hng u.15

Hn ch ca nhng h thng ghi nhn

C s s liu t vong ca TCYTTG ch bao gm mt phn ba trong tng s trng hp t vong ngi trng thnh trn th gii, v phn ln trong s ny l s liu ca cc nc thu nhp bnh qun cao v trung bnh.16, 17 Khng phi quc gia no cng c kh nng

26 Chng 2 cung cp s liu t vong cho TCYTTG, v c c nhng lo ngi v chnh xc ca s liu. mt s nc khc, mc d h thng bo co sinh t bao ph trn ton quc, nhng khng phi tt c cc trng hp t vong u c ghi nhn. Mt s quc gia li ch da vo s liu t vong chun ha trn mu i din ca qun th (nh Trung Quc v n ); mt s nc khc, cc h thng gim st dn s cung cp s liu t vong mt s qun th dn c xc nh.18

Xc nh nguyn nhn t vong bng phng vn (verbal autopsy)

Xc nh nguyn nhn t vong bng phng vn l mt cch gin tip xc nh nguyn nhn t vong t nhng thng tin v nhng biu hin, triu chng v hon cnh trc khi t vong t ngi nh ca i tng t vong.19 nhng nc thu nhp trung bnh v thp, xc nh nguyn nhn t vong bng phng vn l cch duy nht c lng s phn b t vong.20 Xc nh nguyn nhn t vong bng phng vn c s dng ch yu trong cc h thng gim st dn s v h thng gim st sinh t trn mu i din. S a dng ca cc cng c v phng php xc nh lm cho vic so snh s liu nguyn nhn t vong gia cc nc qua thi gian kh khn hn.

Hng ti c lng c th so snh c

Vic m ho sai lch c th xy ra, thm ch cc nc m nguyn nhn t vong do cc chuyn gia c trnh . Nhng l do chnh l: sai lch khi chn on giy chng t khng chnh xc hay khng y vic p dng khng ng cc quy tc ca ICD trong vic la chn nguyn nhn nhng thay i trong vic s dng cc mc m ho cho cc nguyn nhn cha r hay cha xc nh c. V nhng l do ny, vic so snh s liu gia cc nc c th khng chnh xc. TCYTTG cng vi cc nc nhm a ra nhng s liu c lng cp quc gia, s liu c th c chun ha cho nhng khc bit ny (xem Hp 2.3). Hp 2.3. Cc c lng c th so snh t nhng thng k chnh thc Mt nh gi v tnh trng s liu nguyn nhn t vong ton cu cho bit trong s 192 nc thnh vin ca TCYTTG, ch c 23 nc c s liu cht lng cao c xc nh bi: S liu y trn 90% Nguyn nhn t vong khng chnh xc chim di 10% trong tng s cc nguyn nhn t vong S dng M ICD-9 hoc ICD-10 S liu c lng cp quc gia do TCYTTG tnh ton l s liu hiu chnh cho nhng khc bit v mc y v chnh xc ca nhng s liu m cc nc cung cp. c lng ny da vo s liu t h thng ng k sinh t ca 112 nc, ghi nhn khong 18,6 triu trng hp t vong mt nm, i din cho khong mt phn ba tng s t vong trn ton th gii. Thng tin v cc h thng ghi nhn trn mu, cc c s thc a v cc nghin cu dch t hc cng c s dng ci thin nhng c lng ny.

nhng nc c tn ti h thng bo co sinh t v c a vo c s s liu t vong ca TCYTTG

o lng sc khe v bnh tt 27

Giy chng t khng y Nhng nhm dn s ngho khng c theo di Nhiu trng hp t vong khng c thng bo v l do vn ho hay tn gio Tui ca trng hp t vong khng c bo co chnh xc

Mt s yu t khc gp phn lm cho h thng bo co khng ng tin cy l: ghi nhn mun, thiu s liu v li bo co hay phn loi nguyn nhn t vong.19 V phi mt nhiu thi gian cc nc c th xy dng c h thng bo co c cht lng cao, mt s phng php khc thng c la chn xc nh nguyn nhn t vong v c lng t sut t vong.

T sut t vong
T sut t vong (hay t sut t vong th) cho tt c trng hp t vong c tnh theo cng thc sau:
T sut t vong th = S trng hp t vong trong mt khong thi gian xc nh Trung bnh tng qun th trong khong thi gian (x 10n)

Hn ch chnh ca t sut t vong th l t sut ny khng tnh n mt thc t l nguy c t vong thay i tu theo tui, gii tnh, chng tc, tng lp kinh t x hi v cc yu t khc. S l khng hp l nu dng t sut ny so snh gia cc khong thi gian khc nhau hoc gia cc khu vc a l khc nhau. V d, cc m hnh t vong nhng c dn sng trong cc khu th mi pht trin vi nhiu gia nh tr c th s rt khc so vi m hnh t vong cc khu ngh bi bin, ni c nhiu ngi v hu sinh sng. Vic so snh cc t sut t vong gia cc qun th c cu trc tui khc nhau thng c da trn cc t sut chun ho theo tui.

T sut t vong theo tui

T sut t vong c th c biu din cho cc nhm c th trong mt qun th, cc nhm ny c xc nh theo tui, gii tnh, ngh nghip, khu vc a l, hay cho cc nguyn nhn t vong xc nh. V d, t sut t vong theo tui v gii c tnh nh sau:
Tng s t vong mt nhm tui v gii xc nh trong mt qun th mt khu vc xc nh v trong mt khong thi gian xc nh Tng qun th c lng cho cng nhm tui v gii ca qun th trong cng khu vc v khong thi gian

n (x 10 )

T sut t vong t l
i khi thng tin t vong ca qun th c m t bng cch s dng t sut t vong t l, y thc cht l mt t s: l s trng hp t vong v mt nguyn nhn trn 100 hoc 1.000 trng hp t vong trong cng khong thi gian. T sut t vong t l khng cho bit nguy c cc thnh vin trong qun th b nhim hay t vong v mt bnh. Vic so snh cc t sut t l gia cc nhm c th gi nhng khc bit th v. Tuy nhin, tr khi bit trc t sut t vong th hay c trng theo nhm, s khng th bit r s khc bit gia cc nhm l do bin thin t s hay mu s. V d, chng ta c th thy t sut t vong t l i vi tnh trng ung th cc nc pht trin, ni c nhiu ngi gi, cao hn nhiu so vi cc nc ang pht trin, ni c t ngi gi hn, mc d nguy c mc ung th thc s cho c cuc i ca hai nhm quc gia l nh nhau.

28 Chng 2

T vong s sinh
T sut t vong s sinh l ch s thng dng m t tnh trng sc kho ca mt cng ng. N o lng t sut t vong ca tr trong nm u tin ca cuc i, mu s l s tr sinh ra sng trong cng nm. T sut t vong tr em di mt tui c tnh nh sau:
IMR = S t vong trong mt nm ca tr di mt tui Tng s tr sinh ra sng trong cng nm 1000

Vic s dng t sut t vong tr s sinh nh l mt o lng tnh trng sc kho chung cho mt qun th no c da trn c s tha nhn ch s ny c bit nhy cm vi nhng thay i kinh t x hi v vi nhng can thip v chm sc sc kho. T sut t vong tr s sinh gim ti tt c cc vng trn th gii, nhng vn cn tn ti nhiu khc bit ln gia cc nc khc nhau v ngay trong bn thn mt quc gia. (Xem hnh 2.4) Hnh 2.4. Xu hng t sut t vong s sinh ton cu 1950-2000
22

Bng 2.5. T sut t vong tr em di 5 tui mt s nc, 200323

Nc T sut t vong tr em (trn 1000 tr sinh sng) Nam Cc nc thu nhp cao Nht bn Php Canada M Cc nc thu nhp trung bnh Chile 4 5 6 9 N 4 5 5 7

10 (911)

9 (810)

o lng sc khe v bnh tt 29

Argentina Peru Indonesia Cc nc thu nhp thp Cuba Sri Lanka Angola Sierra Leone 19 (1821) 36 (3142) 45 (4049) 16 (1517) 32 (2739) 37 (3340)

8 (710) 17 (1419) 276 (245306) 297 (250340)

6 (57) 13 (1115) 243 (216276) 270 (229310)

T sut t vong tr em
T sut t vong tr em c tnh da trn s tr t vong tui t 1 4 v l mt ch s sc kho c bn. Chn thng khng ch nh, suy dinh dng v cc bnh nhim trng l nguyn nhn t vong thng gp nhm tui ny.T sut t vong tr di 5 tui th hin xc sut (tnh trn 1.000 tr sinh ra) t vong ca mt tr trc khi t n tui th 5. Bng 2.5 cho thy t sut t vong cc quc gia theo hng thu nhp. Nhng c lng khng chc chn cho cc nc thu nhp trung bnh v thp c th hin trong ngoc n. S liu trong bng 2.5 c tnh ton sao cho thng tin c th so snh c gia cc quc gia. T sut t vong trn 1.000 tr sinh ra thay i t 4 Nht Bn (da trn s liu chnh xc) ti 297 vi tr em nam Sierra Leone (S liu khng chc chn dao ng trong khong t 250 n 340 trn 1.000 tr sinh ra). Thu thp s liu chnh xc khng d dng v vy nhng cch tip cn khc thay th cng c pht trin (xem Hp 2.4) Hp 2.4. Nhng phng php khc thu thp thng tin t vong ca tr
nhng ni cha c h thng ghi nhn t vong chnh xc th t vong tr s sinh v tr em c th c c tnh t nhng thng tin thu thp t cc iu tra h gia nh, trong cu hi sau thng c hi: Trong hai nm qua, c tr nh hn hoc bng 5 tui no t vong khng? Nu cu tr li l c, th hi tip ba cu sau: Tr b mt cch y my thng? Tr c bao nhiu thng tui khi mt? Tr b mt l trai hay gi? Nu thng tin v s lng v tui ca tr sng cng c thu thp khi iu tra, th t sut t vong tr s sinh v tr em c th c c lng tng i chnh xc. T vong ca ngi ln c th c o lng da trn cc iu tra h gia nh nu khng sn c thng tin chnh xc t h thng ghi nhn t vong. iu tra h gia nh c mt s hn ch. C th: ngi cung cp thng tin c th khng hiu qung thi gian ca cu hi nhng tr t vong ngay sau khi sinh c th b loi b v v mt s l do vn ho th s tr trai t vong c bo co nhiu hn s tr gi t vong. Tuy nhin, iu tra h gia nh l phng php duy nht c th p dng c mt s cng ng. o lng t vong tr s sinh nhng cng ng thu nhp thp c ngha c bit quan trng nhm gip cc nh lp k hoch hng vo gii quyt nhu cu cng bng trong chm sc sc kho. Thm vo , gim t sut t vong tr cng l mt trong nhng Mc tiu Pht trin Thin nin k (xem Chng 10)

30 Chng 2

T sut t vong m
T sut t vong m cho bit nguy c b m t vong do nhng nguyn nhn lin quan n sinh n, thai nghn. Ch s thng k quan trng ny c th b lng qun do rt kh tnh chnh xc, v c tnh nh sau:
MMR = S t vong c lin quan n thai sn ca b m trong 1 nm Tng s tr sinh trong cng nm (x 10n)

T sut t vong m dao ng t khong 3 trn 100.000 ca sinh n cc nc thu nhp cao n 1.500 trn 100.000 cc nc thu nhp thp. Tuy nhin, so snh ny cng khng phn nh y nguy c t vong do cc nguyn nhn lin quan n thai sn ln hn nhiu cc nc ngho.

T sut t vong tui trng thnh

T sut t vong tui trng thnh c nh ngha l xc sut t vong trong nhm tui t 15 n 60 trn 1.000 ngi. T sut t vong ngi trng thnh l mt cch phn tch khong cch sc kho gia cc quc gia trong nhm tui lao ng chnh. Xc sut t vong tui trng thnh ln hn nam gii so vi n gii hu ht cc quc gia. S khc bit gia cc quc gia cng rt ln. Ti Nht Bn, t sut ny nh hn 1 trong 10 nam gii (v 1 trong 20 n gii), trong khi con s ny Angola l 2/3 vi nam gii v 1/2 vi n gii (Xem Bng 2.6) Bng 2.6. T sut t vong tui trng thnh ti mt s nc, 2004
Nc Cc nc thu nhp cao Nht bn Canada Php M Cc nc thu nhp trung bnh Chile Argentina Peru Indonesia Cc nc thu nhp thp Cuba Sri Lanka Angola Sierra Leone T sut t vong trn dn s 1000, trong tui 1560 Nam N 92 91 132 137 133 173 184 239 131 232 591 579 45 57 60 81 66 90 134 200 85 119 504 497

Tui th trung bnh

Tui th trung bnh l mt s o na v tnh trng sc kho ca mt qun th v thng xuyn c s dng. N c nh ngha l s nm trung bnh ca mt c nhn k vng sng n mt tui no nu cc t sut t vong hin ti vn duy tr. Khng phi lun lun d dng din gii l do cho s khc bit v tui th trung bnh gia cc nc vi nhau; cc m hnh khc nhau c th ny sinh tu theo cc cng thc o lng c s dng.

o lng sc khe v bnh tt 31

Hnh 2.5. Xu hng sng k vng ton cu 1950-200028

Trn ton th gii, tui th trung bnh lc sinh gia tng t 46,5 nm trong giai on 1950 1955 ti 65,0 nm trong giai on 1995 2000 (Xem Hnh 2.5). Tuy nhin mt s nc xu hng ny b o ngc do AIDS nh nhng nc cn sa mc Sahara. Xu hng o ngc ny cng xut hn Lin bang X Vit khi c 1 2 trng hp t vong nam gii trong tui 1560, phn ln l do ung ru v ht thuc l.26 Tui th trung bnh lc sinh, mt ch s v tnh trng sc kho chung, coi t vong trong thi k tr th quan trng hn vo cui i. Bng 2.7 l s liu mt s nc. V s liu c da trn t sut c trng theo tui, c th cn mt s tnh ton b sung c th so snh gia cc quc gia; khong c lng c th hin trong ngoc n. Khong tin cy c th rt ln nh i vi Zimbabue nhng cng c th rt chnh xc nh Nht Bn, nc c h thng ghi nhn hon chnh. Bng 2.7. Tui th trung bnh cho nam v n mt s nc
Nc Zimbabue Lin bang Nga Ai Cp Trung Quc Mexico M Nht Bn Tui th trung bnh khi sinh N Nam 34 72 70 74 77 80 86 37 59 66 70 72 75 79

S liu ny th hin s thay i ln v tui th trung bnh gia cc nc. V d, mt b gi sinh ti Nht Bn nm 2004 c th d tnh sng n nm 86 tui, trong khi mt b gi sinh ti Zimbabue trong cng thi im s sng n khong 3038 tui. hu ht cc nc, n gii sng lu hn nam gii.

T sut chun ho theo tui

Mt t sut t vong chun ho theo tui (i khi gi l t sut hiu chnh theo tui) l mt s o tm tt v t sut t vong ca mt qun th nu nh n c cu trc tui chun. C th chun ha t sut bng cch trc tip hoc gin tip (xem Hp 2.5). Chun ho t sut cho php so snh gia nhng qun th c cu trc tui khc nhau. Chun ha cng c th c p dng vi cc c tnh khc vi tui. Vic ny l cn thit

32 Chng 2 khi so snh hai hay nhiu qun th khc nhau v mt s c tnh c bn (tui, chng tc, tnh trng kinh t x hi ) c nh hng mt cch c lp ti nguy c t vong. Hp 2.5: Chun ha trc tip v gin tip t sut bnh
Chun ha trc tip l phng php c p dng nhiu hn, bng cch p dng t sut mc bnh ca qun th so snh vo qun th chun. Quy trnh ny cho ta s trng hp bnh k vng nu cc t sut mc bnh theo tui qun th chun cng ging nh qun th nghin cu. T sut chun ha c s dng bt c khi no thch hp, t sut bnh hay t sut t vong. Vic la chn qun th chun l tu , nhng c th c vn nu so snh t sut ca nhng nc thu nhp thp vi cc nc thu nhp cao. Chi tit v cc phng php 31 chun ho c th tham kho trong cun Ti liu ging dy Thng k Y t .

Qun th chun thng c s dng l: qun th th gii Segi 29 qun th chun Chu u da trn qun th Thy in qun th chun ca TCYTTG, da trn tng th cc qun th trung bnh d kin th gii nm 2000 2025 30 T sut chun ha theo tui (xem Bng 2.8) khng lm nh hng n sp xp th hng chung khi so snh t sut ca cc qun th khc nhau. Bng 2.8 Cc t sut t vong do ly nhim bnh h hp nam gii chun ho trc tip, v xp hng 5 quc gia s dng 3 qun th chun ho khc nhau
Nc T sut chun ho theo tui (trn 100000) Segi c Cuba Mauritius Singapore Turmenistan 6,3 27,2 45,2 71,9 114,2 Chu u 10,1 44,2 72,6 120,8 87,9 Dn s TCYTTG 7,9 34,6 56,6 93,3 91,2 Xp hng cc quc gia theo t sut chun ho theo tui Segi 5 4 3 2 1 Chu u 5 4 3 1 2 Dn s TCYTTG 5 4 3 1 2

Cc t sut chun ho theo tui loi b c nh hng do phn b tui khc nhau n cc t sut t vong hay bnh tt c so snh. V d, c s dao ng ln gia cc nc trong s liu t sut t vong th do cc bnh thuc h tun hon (Bng 2.9). Phn Lan c t sut th cao xp x gp 3 ln t sut th ca Brazil, nhng c cng t sut chun ho. Tng t, M c t sut th cao hn 2 ln t sut ca Brazil, tuy nhin t sut chun ho theo tui tng t Brazil. V vy, s khc bit gia cc nc ny khng ln nh s khc bit gia cc t sut t vong th. Cc nc thu nhp cao c t l ngi cao tui trong dn s ca h cao hn nhiu so vi cc nc thu nhp thp v trung bnh, v nhng ngi cao tui c t sut t vong do bnh tim mch cao hn so vi nhng ngi tr tui. Tt c cc t sut ny tt nhin chu nh hng bi cht lng ca s liu gc v nguyn nhn t vong.

o lng sc khe v bnh tt 33

Bng 2.9 T sut t vong th v chun ho theo tui (trn 100 000) vi bnh tim ti 3 quc gia (c nam v n gii), 2002
Nc Brazil Phn Lan M T sut t vong th 79 240 176 T sut t vong chun ho theo tui 118 120 105

Tnh trng bnh tt

Cc t sut t vong c bit hu ch khi tm hiu cc bnh c t l cht-mc cao. Tuy nhin, nhiu bnh c t l cht-mc thp, nh hu ht cc bnh tm thn, bnh h c xng, vim khp dng thp, thy u v quai b, khi s liu v tnh trng bnh tt hu ch hn l cc t sut t vong. S liu v bnh thng gip sng t nhng l do v cc chiu hng t vong c th. Nhng thay i v t sut t vong c th do nhng thay i trong t sut mc bnh hay t l cht-mc. V d, s suy gim gn y v t sut t vong bnh tim mch nhiu nc pht trin c th do gim t l mi mc hay gim t l cht-mc. V cu trc tui ca qun th thay i theo thi gian, nn vic phn tch theo thi gian cn phi da trn cc t sut mc bnh v t vong chun ho theo tui. Cc ngun s liu bnh tt bao gm: Nhp v xut vin Khm v iu tr ngoi tr cc trm y t tuyn c s Dch v c bit (nh iu tr chn thng) H thng ghi nhn tnh trng bnh (nh ung th v d tt bm sinh) c th s dng trong cc nghin cu dch t hc, cc s liu ny cn phi ph hp v d tip cn. mt s nc, yu cu bo mt h s bnh n c th cn tr vic tip cn cc s liu bnh vin ca cc nghin cu dch t hc. Mt h thng ng k tp trung nhiu vo s liu hnh chnh hay ti chnh hn l cc c im c nhn v chn on cng c th lm gim gi tr dch t ca s liu v dch v y t thng nht. T l nhp vin b nhiu yu t nh hng hn l tnh trng bnh tt ca mt qun th, v d s sn c ca ging bnh, chnh sch nhp vin v cc yu t x hi. Do c nhiu hn ch trong s liu bo co nh k v tnh trng bnh tt, nhiu nghin cu dch t v tnh trng mc bnh phi da vo vic thu thp s liu mi, s dng nhng b cu hi c thit k c bit v cc k thut khm sng lc. iu ny to iu kin cho cc nh nghin cu tin tng hn v s liu v cc t l, t sut c tnh t s liu .

Tn tt (Disability)
Nh dch t hc khng ch quan tm n s xut hin ca tnh trng bnh, m cn n cc hu qu ca bnh nh: khim khuyt (impairments), gim kh nng (disabilities) v tn ph (handicaps). Cc hu qu ny m t trong nh ngha quc t v chc nng, gim kh nng v sc kho ca TCYTTG (ICF).32 ICF miu t cch con ngi sng vi tnh trng sc kho ca mnh. V cc chc nng v gim chc nng ca mt c nhn din ra trong mt hon cnh xc nh, ICF cng

34 Chng 2 bao gm mt danh sch cc yu t mi trng. ICF l mt cng c hu ch hiu bit v o lng cc kt qu sc kho. ICF c th c s dng trong lm sng, dch v hay iu tra y t, mc c nhn hay qun th. Nhng thng s c bn ca ICF l: Khim khuyt (impairment): Bt k s tn hi hay bt bnh thng no v cu trc hay chc nng tm l, sinh l hay gii phu. Gim kh nng (disability): Bt k s hn ch hay thiu ht no (bt ngun t mt khim khuyt) v kh nng thc hin mt hot ng theo cch hoc trong phm vi c coi l bnh thng i vi mt ngi. Tn tt (Handicap): Mt s thit thi ca mt c th no , bt ngun t mt khim khuyt hay mt gim kh nng, m lm hn ch hay cn tr vic hon thnh mt vai tr bnh thng (ty thuc tui, gii v cc yu t x hi v vn ho) ca c th .

Hp 2.6 m t mi quan h gia cc tnh trng khng t vong khc nhau. Hp 2.6. Lc nh gi nhng hu qu sc kho khng dn n t vong
Bnh tt Bi lit Tn thng no Khim khuyt Lit chn Tr c chm chp Gim kh nng Khng c kh nng i li Kh khn trong hc tp Tn tt Tht nghip S c lp x hi

Vic o lng tnh trng hin mc tn tt rt kh, tuy nhin cc o lng ny ngy cng tr nn quan trng trong nhng x hi m tnh trng bnh cp tnh hay bnh gy t vong ang gim i v ni c s ngi cao tui b tn tt ngy cng tng.

Cc yu t quyt nh, ch s sc kho, v cc yu t nguy c

Yu t quyt nh sc kho
Cc yu t quyt nh sc kho c nh ngha l nhng yu t x hi, kinh t, vn ho v mi trng c bn quyt nh sc kho v bnh tt. Phn ln cc yu t ny nm ngoi lnh vc y t.3335

Ch s sc kho
Ch s sc kho l mt bin s, c th c o trc tip phn nh tnh trng sc kho ca ngi dn trong mt cng ng. Hng nm, TCYTTG bo co s liu mi nht theo 50 ch s sc khe.25 Ch s sc kho cng c th c dng trong nhng thnh phn tnh ton ch s pht trin x hi rng hn. V d tt nht l Ch s Pht trin Con ngi, cho php xp hng cc quc gia mi nm tng ng vi mc pht trin kinh t, t l m ch, gio dc, v tui th trung bnh (http://hdr.uhdp.org)

Yu t nguy c
Mt yu t nguy c l mt kha cnh thi quen c nhn hay phi nhim mi trng c lin h vi xc sut tng dn s xut hin bnh. V c th iu chnh cc yu t nguy c, can thip c th thay i yu t nguy c theo chiu hng c li gim xc sut xut hin bnh. Tc ng ca can thip c th xc nh c bng cch s dng cng o lng v cng tnh trng. (xem Hp 2.7)

o lng sc khe v bnh tt 35

Hp 2.7 o lng cc yu t nguy c

Cc yu t nguy c c th bao gm ht thuc l hay ung ru, n king, hot ng th lc, huyt p hay bo ph. V cc yu t nguy c c th c s dng chn on bnh tt trong tng lai, nhng o lng ti mt qun th l rt quan trng nhng cng rt kh khn. Thuc l c th c xc nh bng cch t ghi nhn tnh trng ht (c/khng), s lng ht, hay cc du hiu sinh hc (continine huyt thanh). Tuy nhin, cc iu tra khc nhau s dng phng php, k thut, tiu ch xc nh nguy c hay kt qu lm sng khc nhau (v d nh tiu ng hay tng huyt p). Thm vo , cc iu tra ch c th i din cho mt phn nh cc nhm dn s ca mt quc gia, qun hay thnh ph. Nhng khc bit v phng php ny cho thy kh khn trong vic so snh kt qu gia cc iu tra v cc quc gia khc nhau. Nhiu n lc c thc hn chun ho cc phng php o lng yu t nguy c trn phm vi ton cu, bao gm c D n MONICA ca TCYTTG trong nhng nm 1980 v 1990.36,37 Mi y, phng php STEPS ca TCYTTG o lng yu t nguy c cp qun th cung cp quy trnh v ti liu khuyn khch cc quc gia thu thp s liu mt cch chun ha.38,39 S liu t cc quc gia c th c hiu chnh theo nhng sai lch bit c th so snh. Bc ny cng l cn thit v cc quc gia thc hin iu tra chun trong cc thi im khc nhau. Nu nh cc yu t nguy c thay i theo thi gian, nhng thng tin v xu hng thay i s c s dng hiu chnh s liu theo nm bo co chun.

Cc o lng sc kho qun th tng hp khc

Cc nh hoch nh chnh sch phi i mt vi thch thc trong sp xp u tin phng v kim sot bnh, trong khi vn chu trch nhim d on cc u tin cho tng lai. Quyt nh ny phi da vo cc o lng sc khe tng hp m t quy m bnh tt ca qun th. Cc o lng phi kt hp c t vong v thi gian mang bnh theo mt cch ng nht, s dng cng mt n v o lng. Nhng o lng ny chnh l n v ghi nhn gnh nng bnh tt trong qun th. y chnh l cch theo di v nh gi sc khe qun th, t c th trin khai nhanh chng cc hnh ng phng chng v kim sot ngay khi cn thit. T sut t vong khng th phn nh y bc tranh v cc yu t khc nhau tc ng n sc khe qun th. Qung thi gian sng c gn vi khi nim cht lng cuc sng c th c phn nh bng cc o lng qun th di y: S nm sng tim tng b mt (Potential life lost PLL) da vo s nm sng b mt i do t vong sm (trc mt mc tui bt k) K vng sng kho mnh (Healthy life expectancy HALE) K vng sng khng b gim chc nng (Disability-free life expectancy DFLE) S nm sng hiu chnh theo cht lng (QUALYs) S nm sng hiu chnh tnh trng tn tt (DALYs)

D n Gnh nng bnh tt 40 kt hp nh hng t vong sm v gim chc nng. Bng mt o lng duy nht, d n ghi nhn c nh hng qun th ca nhng tnh trng t vong v khng t vong. o lng c s dng ch yu l DALY, kt hp

S nm sng iu chnh theo tnh trng tn tt

36 Chng 2 S nm sng b mt (Years of lost life YLL) tnh theo s t vong mi tui, nhn vi s nm sng cn li theo tui th trung bnh chun ca th gii S nm sng b mt do gim chc nng (YLD), s trng hp mi mc do chn thng hay m au nhn vi thi gian trung bnh ca bnh v mt trng s phn nh mc nghim trng ca bnh t 0 (hon ton kho mnh) n 1 (t vong).

Mt DALY l mt nm sng khe mnh b mt v gnh nng bnh tt chnh l khong cch gia tnh hnh sc kho hin ti ca qun th v tnh trng l tng m mi ngi sng n gi, khng b gim chc nng. Qun th tham kho tiu chun c tui th trung bnh lc sinh l 82,5 n v 80,0 nam. Khu tr thi gian v trng s tui, thp hn i vi nhng nm tui tr so vi tui gi, c s dng tnh gi tr DALY chun nh ghi nhn trong bo co Sc khe ton cu ca TCYTTG. Vi trng s tui v khu tr thi gian, mt trng hp t vong s sinh tng ng vi 33 DALY, v t vong trong tui t 5 20 l khong 36 DALY. V th 3.300 DALY ca mt qun th c th tng ng vi gnh nng ca 100 tr s sinh t vong hay 5.500 ngi 50 tui sng mt nm trong tnh trng m la. DALY c thit k nh hng cc chnh sch u t ca Ngn hng th gii cho y t v thng bo tnh hnh u tin ton cu cho cc nghin cu v chng trnh y t. Phn tch DALY do nhiu nguyn nhn v yu t nguy c khc nhau cho thy nhiu ci nhn mi v tm quan trng ca phng bnh.42

So snh s xut hin bnh

o lng s xut hin bnh hay cc tnh trng sc kho khc nhau mi ch l im xut pht ca qu trnh dch t hc. Bc tip theo l so snh s xut hin bnh gia hai hay nhiu nhm ngi c tnh trng phi nhim khc nhau. Mt ngi c th c hoc khng phi nhim vi mt yu t nguy c ang nghin cu. Nhm khng phi nhim thng c s dng lm nhm i chng. Ngi c phi nhim c th c nhng mc v thi gian phi nhim khc nhau (xem Chng 9). Tng lng phi nhim ca mt ngi vi mt yu t no c th c gi l liu. Chng ta c th so snh qu trnh xut hin xc nh nguy c mt hu qu sc khe ny sinh do phi nhim. Chng ta c th so snh mt cch tng i cng nh tuyt i bng cc o lng mnh ca s kt hp gia phi nhim v hu qu.

So snh tuyt i
Khc bit v nguy c
S khc bit nguy c hay cn gi l nguy c vt tri, l s chnh lch gia cc t sut xut hin bnh gia nhm c phi nhim v khng phi nhim. y l mt o lng tt v mc ca mt vn y t cng cng gy ra bi phi nhim. V d, t s liu trong Bng 2.4, khc bit t sut mi mc t qu ph n ht thuc so vi nhng ph n cha bao gi ht thuc l 31,9/100.000 nm ngi. Khi so snh hai hay nhiu nhm, iu quan trng l cc nhm tng ng cng nhiu cng tt, tr yu t ang c phn tch. Nu cc nhm khc bit nhau v tui, gii v.v, t sut phi c chun ho trc khi so snh.

o lng sc khe v bnh tt 37

Phn s quy thuc (phi nhim)

Phn s quy thuc (phi nhim) hay phn s sinh thi (phi nhim), l t l tt c cc trng hp b bnh do mt phi nhim no . Vi s liu trong Bng 2.4, phn s quy thuc ca ht thuc l dn n t qu nhng ph n ht thuc l l [(49,6 17,7)/49,6] x 100% = 64%. Khi mt phi nhim c cho l nguyn nhn ca mt bnh th phn s quy thuc chnh l t l bnh trong qun th phi nhim c th gim c nu loi b c phi nhim. Trong v d trn, ngi ta k vng lm gim 64% nguy c t qu nhng ph n ht thuc nu h b thuc, vi gi thit rng ht thuc l va l nguyn nhn li va c th phng trnh c. Phn s quy thuc l mt cng c hu ch nh gi nhng u tin i vi hot ng y t cng cng. V d c ht thuc l v nhim khng kh u l nguyn nhn ca ung th phi, nhng nguy c quy thuc do ht thuc thng ln hn nhiu nguy c quy thuc do nhim khng kh. Ch nhng cng ng c t l ht thuc rt thp m nhim khng kh trong hoc ngoi nh li trm trng th nhim khng kh c th l nguyn nhn ch yu ca ung th phi. hu ht cc nc, vic kim sot ht thuc l c t u tin trong cc chng trnh phng trnh ung th phi.

Nguy c quy thuc qun th

Nguy c quy thuc qun th (PAR) l t l mi mc bnh ca mt qun th c mi lin quan ti (hoc quy cho) vic phi nhim vi mt yu t nguy c.11 o lng ny hu ch trong vic xc nh tm quan trng tng i ca cc yu t phi nhim i vi ton b qun th v l t l m mi mc bnh trong ton b qun th gim i nu loi b c yu t phi nhim. PAR c c lng bng cng thc sau:

PAR =

I p Iu Ip

Trong : I p l mi mc bnh trong ton b qun th v

I u l mi mc bnh trong nhm khng phi nhim.

So snh tng i
Nguy c tng i
Nguy c tng i (cn c gi l t s nguy c) l t s nguy c xut hin nhm c phi nhim vi nhm khng phi nhim. Vi s liu trong Bng 2.4, t s nguy c t qu ph n ht thuc l so vi nhng ngi cha bao gi ht thuc l l 2,8 (49,6/17,7). T s nguy c ny l mt ch s tt hn v mnh ca s kt hp so vi s khc bit nguy c, v n c biu din mt cch tng i so vi mc xut hin bnh c bn. Khng ging khc bit nguy c, t s nguy c c lin quan ti ln ca cc o lng mi mc ca nhm so snh, o lng ny cn lin quan n ln ca nguy c nn, cc qun th c khc bit nguy c tng t nhau c th c cc t s nguy c rt khc nhau, ty thuc vo ln ca nguy c nn.

38 Chng 2 T s nguy c c s dng nh gi kh nng mt s kt hp c i din cho mt mi quan h nhn qu khng. V d, t s nguy c ung th phi nhng ngi nghin thuc l nng so vi nhng ngi khng ht xp x 20. T s nguy c ny rt cao v cho thy mi lin quan ny kh c th l do ngu nhin. D nhin vi cc t s nguy c nh hn cng c th cho thy mi quan h nhn qu, nhng cn phi thn trng loi tr cc gii thch c th khc (xem Chng 5).

Nguy c quy thuc (attributable risk)

Nguy c quy thuc l t l ca mt bnh hay mt tnh trng nhng ngi phi nhim c th quy cho phi nhim. y l mt thut ng hu ch hn cho cc mc ch y t cng cng v ch s ny phn nh, thng biu din di dng phn trm, nguy c mc bnh c th gim nu loi b hay kim sot phi nhim. S dng nguy c quy thuc, chng ta c th c tnh s ngi bnh khng phi do phi nhim, bng cch ly t sut bnh (thng l mi mc hay t vong) nhm c phi nhim tr t sut nhm khng phi nhim. V d, nu c 6 trng hp t vong trn 100 ngi ht thuc, v 1 trng hp t vong trn 100 ngi khng ht thuc, nguy c quy thuc s l 5 trn 100. y ta gi nh rng cc nguyn nhn khc c nh hng nh nhau nhm c phi nhim v nhm khng phi nhim. Tm li, c rt nhiu cc o lng nghin cu qun th. Chng 3 cp ti nhiu cch o lng ny trong bi cnh ca tng thit k nghin cu.

Cu hi
2.1. Ba o lng tn s bnh trng dch t hc l g v ba o lng ny c lin quan vi nhau nh th no ? 2.2. T l hin mc c phi l mt o lng tt tn s bnh tiu ng loi 2 trong cc qun th khc nhau khng? Hy gii thch s bin i t l hin mc tiu ng trong Bng 2.3? 2.3. u l nguy c quy thuc qun th v phn s nguy c (t l) nhng ngi ht thuc trong v d Bng 2.4? 2.4. o lng no dng so snh tn s bnh trong cc qun th v cc o lng ny cho bit thng tin g? 2.5. Nguy c tng i ca mc ung th phi do ht thuc th ng thp, nhng nguy c quy thuc qun th rt ln. Hy gii thch iu ny? 2.6. L do chnh ca vic chun ho cc t l theo qun th c phn b tui chun l g? (V d, qun th chun ca TCYTTG) 2.7. Nu mun s t vong do ung th trn u ngi ln nht u trong mt quc gia, s dng o lng no sau y l hp l nht: t sut t vong th hay t sut chun ho theo tui? 2.8. T sut t vong th do tt c cc loi ung th trn 100.000 ngi Cte dlvoire l 70,5 v t sut t vong chun ho theo tui l 160,2 trn 100.000 ngi. iu g l gii s khc bit ln gia 2 t sut ny? 2.9. T sut t vong th do tt c cc loi ung th Nht Bn l 241,7 trn 100.000 ngi v t sut t vong th do tt c cc loi ung th Cte dlvore l 70,5 trn 100.000 ngi. C phi t sut t vong Nht Bn cao hn Cte dlvore khng?

o lng sc khe v bnh tt 39

Ti liu tham kho

1. Constitution of the World Health Organization. New York, World Health Organization, 1946. 2. Jong-wook L. Global health improvement and WHO: shaping the future. Lancet 2003;362:2083-8. Medline doi:10.1016/S0140-6736(03)15107-0 3. Torrence ME. Understanding Epidemiology. Mosbys Biomedical Science Series. Missouri, Mosby-Year Book Inc., 1997. 4. Special Writing Group of the Committee on Rheumatic Fever. Endocarditis, and Kawasaki Disease in the Young of the American Heart Association. Guidelines for the diagnosis of rheumatic fever, Jones criteria, 1992 update. JAMA 1992;268:2069-73. Medline doi:10.1001/jama.268.15.2069 5. The management of acute respiratory infections in children. Practical guidelines for outpatient care. Geneva, World Health Organization,1995. 6. WHO recommended surveillance standards. Geneva, World Health Organi- zation. 1997. 7. Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults. MMWR Recomm Rep 1993;1992:41. 8. Prineas RJ, Crow RS, Blackburn Hnh The Minnesota code manual of electrocardiographic findings: standards and procedures for measurement and classification. Stoneham, MA, Butterworth Publications, 1982. 9. Luepker RV, Evans A, McKeigue P, Reddy KS. Cardiovascular Survey Methods, 3rd ed. Geneva, World Health Organization, 2004. 10. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000;36:959-69. Medline doi:10.1016/S0735-1097(00)00804-4 11. Last JM. A dictionary of epidemiology, 4th ed. Oxford, Oxford University Press, 2001. 12. King H, Rewers M. Global estimates for prevalence of diabetes mellitus and impaired lucose tolerance in adults. WHO Ad Hoc Diabetes Reporting Group. Diabetes Care 1993;16:157-77. Medline 13. Colditz GA, Bonita R, Stampfer MJ, Willett WC, Rosner B, Speizer FE, et al. Cigarette smoking and risk of stroke in middle-aged women. N Engl J Med 1988;318:937-41. Medline 14. International Statistical Classification of Diseases and Related Health Problems. Tenth Revision. Vol. 1. Geneva, World Health Organization, 1992. 15. Shibuya K. Counting the dead is essential for health. Bull World Health Organ 2006;84:170-1. Medline 16. Shibuya K, Boerma T. Measuring progress towards reducing health inequalities. Bull World Health Organ 2005;83:162. Medline 17. Mathers CD, Ma Fat D, Inoue M, Rao C, Lopez AD. Counting the dead and what they died from: an assessment of the global status of cause of death. Bull World Health Organ 2005;83:171-7. Medline 18. Population, Health and Survival at INDEPTH Sites. Vol 5. Ottawa, The International Development Research Centre, 2002. 19. Sibai AM. Mortality certification and cause of death reporting in developing countries. Bull World Health Organ 2005;83:83. 20. Setel PW. Sample registration of vital events with verbal autopsy: a renewed commitment to measuring and monitoring vital statistics. Bull World Health Organ 2005;83:611-7. Medline 21. Soleman N, Chandramohan D, Shibuya K. Verbal autopsy: current practices and challenges. Bull World Health Organ 2006;84:239-45. Medline doi: 10.2471/BLT.05.027003

40 Chng 2 22. Moser K, Shkolnikov V, Leon DA. World mortality 19502000: divergence replaces convergence from the late 1980s. Bull World Health Organ 2005;83:202-9. Medline 23. World Health Report 2005: Make every mother and child count. Geneva, World Health Organization, 2005. 24. Feachem RGA, Kjellstrom T, Murray CJL, Over M, Phillips MA. The health of adults in the developing world. Oxford, Oxford University Press, 1992. 25. World Health Statistics 2006. Geneva, World Health Organization, 2006. 26. McKee M, Zatonski W. Public Health in Eastern Europe and the Former Soviet Union. In: Beaglehole R, ed. Global Public Health: A New Era. Oxford, Oxford University Press, 2003. 27. Barford A, Dorling D, Davey Smith G, Shaw M. Life expectancy: women now on top everywhere. BMJ 2006;332:808. Medline doi:10.1136/bmj.332.7545.808 28. World Health Report 2006: Working together for health. Geneva, World Health Organization, 2006. 29. Waterhouse J. Muir, C., Correa, P., Powell, J. & Davis, W.Cancer Incidence in Five Continents, Vol. III. IARC Scient. Publ. 15. Lyon, IARC, 1976. 30. Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJL, Lozano R, Inoue M. Age standardization of rates: a new WHO standard. (GPE discussion paper series no. 31). Geneva, World Health Organization, 2001. 31. Lwanga SK, Tye CY, Ayeni O. Teaching health statistics: lesson and seminar outlines, 2nd ed. Geneva, World Health Organization, 1999. 32. International classification of impairments, disabilities and handicaps. A man- ual of classification relating to the consequences of disease. Geneva, World Health Organization, 1980. 33. Lee JW. Public health is a social issue. Lancet 2005;365:1005-6. doi:10.1016/ S0140-6736(05)66541-5 34. Irwin A, Valentine N, Brown C, Loewenson, R, Solar O, et al. The Commission on Social Determinants of Health: Tackling the social roots of health inequities. PLoS Med 2006;3:e106. d 35. Marmot M. Social determinants of health inequalities. Lancet 2005;365: 1099-104. Medline 36. Tunstall-Pedoe H, Vanuzzo D, Hobbs M, Mahonen M, Cepaitis Z, Kuulasmaa K, et al. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet 2000;355:688-700. 37. Tolonen H, Dobson A, Kulathinal S, for the WHOMONICA Project. Assessing the quality of risk factor survey data: lessons from the WHO MONICA Project. Eur J Cardiovasc Prev Rehab 2005;13:104-14. 38. Armstrong T, Bonita R. Capacity building for an integrated noncommunicable disease risk factor surveillance system in developing countries. Ethn Dis 2003;13:S2-13. 39. Bonita R, Winkelmann R, Douglas KA, de Courten M. The WHO STEPwise approach to surveillance (STEPS) of noncommunicable disease risk factors. In: McQueen DV, Puska P, eds. Global Risk Factor Surveillance. New York, Kluwer e Academic/Plenum Publishers, 2003:922. 40. Ezzati M, Lopez AD, Rodgers A, Murray CJL. Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. Geneva, World Health Organization, 2004. 41. World Bank. World Development Report: Investing in Health. Washington: World Bank, 1993. 42. The World Health Report: Reducing Risks, Promoting Healthy Life. Geneva, World Health Organization, 2002.

41

Chng 3

Cc thit k nghin cu
Thng ip chnh
La chn thit k nghin cu ph hp l mt bc c bn trong mt iu tra dch t hc. Mi thit k nghin cu u c im mnh v im yu ring. Cc nh dch t hc cn xem xt ton b cc ngun sai s v nhiu, v c gng lm gim chng. Cc vn o c l rt quan trng trong dch t hc, cng nh trong cc ngnh khoa hc khc.

Quan st v thc nghim

Cc nghin cu dch t hc c th c phn loi thnh quan st hoc thc nghim. Cc loi thit k nghin cu s dng rng ri nht c trnh by bng 3.1 cng vi cc tn gi thay th v n v nghin cu khc nhau. Cc khi nim ct bn tri c s dng trong sut cun sch ny. Bng 3.1: Cc loi nghin cu dch t hc
Loi nghin cu Cc nghin cu quan st Cc nghin cu m t Cc nghin cu phn tch Sinh thi Ct ngang Bnh chng Thun tp Cc nghin cu thc nghim Cc th nghim ngu nhin c i chng Cc th nghim cm ngu nhin c i chng Th nghim thc a Th nghim cng ng Nghin cu can thip ti cng ng Ngi kho Cng ng Tng quan Hin mc Bnh tham chiu Theo di Cc nghin cu can thip Cc th nghim lm sng Cc c th Cc nhm Cc qun th Cc c th Cc c th Cc c th Tn gi khc n v nghin cu

42 Chng 3

Cc nghin cu quan st
Cc nghin cu quan st cho php mi s kin din ra theo t nhin: nh nghin cu o lng nhng khng can thip. Chng bao gm cc nghin cu c th c gi l m t hoc phn tch: Mt nghin cu m t c gii hn trong vic m t s xut hin ca mt bnh trong mt qun th v thng l bc u tin trong mt iu tra dch t hc Mt nghin cu phn tch i xa hn bng vic phn tch cc mi lin h gia tnh trng sc kho v cc bin khc. Khc vi cc nghin cu m t n gin nht, hu ht cc nghin cu dch t hc u c c tnh phn tch. Cc nghin cu m t n thun rt him, nhng s liu m t trong cc bo co thng k y t l mt ngun d liu hu ch ca cc tng cho cc nghin cu dch t hc. Cc thng tin m t hn ch (v d nh m t mt lot trng hp) trong cc c im ca mt vi bnh nhn vi mt bnh c bit c m t nhng khng c so snh vi mt qun th tham chiu, thng khi xng cho cc nghin cu dch t hc chi tit hn. V d, vic m t bn nam thanh nin vi cc triu chng him gp trc y ca bnh vim phi vo nm 1981 l bc u tin trong mt lot cc nghin cu dch t hc v mt tnh trng bnh m sau ny c bit l Hi chng suy gim min dch mc phi (AIDS).

Cc nghin cu thc nghim

Cc nghin cu thc nghim hay can thip lin quan n mt c gng tch cc thay i mt yu t quyt nh bnh v d nh mt phi nhim hoc mt hnh vi hoc l tin trnh ca mt bnh thng qua iu tr, v tng ng vi thit k th nghim trong cc ngnh khoa hc khc. Tuy nhin, chng c mt s hn ch, do sc kho ca nhng ngi trong nhm nghin cu c th b e do. Cc thit k nghin cu thc nghim chnh bao gm: Cc th nghim ngu nhin c i chng s dng bnh nhn lm i tng nghin cu (th nghim lm sng) Cc th nghim thc a trong thnh vin tham gia l nhng ngi kho mnh, v Cc th nghim cng ng trong cc thnh vin tham gia l chnh cc cng ng. Trong tt c cc nghin cu dch t hc mt iu c bn l phi c mt nh ngha r rng v trng hp bnh c iu tra bng cch m t cc triu chng, cc du hiu hoc cc c tnh khc ch r rng mt ngi c bnh. Mt nh ngha r rng v mt ngi b phi nhim cng rt quan trng. nh ngha ny cn bao gm tt c nhng c tnh ch r mt ngi ang b phi nhim vi mt yu t nghi ng. Nu khng c cc nh ngha r rng v bnh v phi nhim, rt kh din gii s liu t mt nghin cu dch t hc.

Dch t hc quan st
Cc nghin cu m t
Mt nh ngha n gin tnh trng sc kho ca mt cng ng, da trn s liu thng nht sn c hoc s liu ly t cc iu tra c bit c m t Chng 2,

Cc thit k nghin cu 43 thng l bc u tin trong mt iu tra dch t hc. rt nhiu quc gia loi nghin cu ny do trung tm quc gia v thng k y t thc hin. Cc nghin cu m t ngho nn khng dng phn tch cc mi lin h gia phi nhim v kt qu. Chng thng da vo cc thng k t vong v c th kim tra cc loi t vong theo tui, gii, hoc dn tc trong nhng khong thi gian c bit hoc trong cc quc gia khc nhau. Mt v d kinh in ca s liu m t c biu din Hnh 3.1, th hin loi hnh t vong m Thu in t gia th k mi tm, cho bit cc t sut t vong m trn 100.000 tr sinh ra sng.2 S liu ny c th c gi tr cao khi xc nh cc yu t gy ra xu hng thp xung nh vy. Vic nghin cu nhng thay i trong cc iu iu kin sng ca ph n vo nhng nm 1860 v 1870 m c th gy ra s tng tm thi t sut t vong m ti thi im l iu ng quan tm. Trn thc t, l thi gian m Thu in trong tnh trng rt ngho i v gn mt triu c dn Thu in phi di c; hu ht chuyn sang Hp chng quc Hoa K. Hnh 3.1. Cc t sut t vong ti Thu in, 175019752

Hnh 3.2 cng da trn thng k t vong thng quy, l mt v d v s thay i cc t sut t vong ca bnh tim theo thi gian ti su quc gia. Hnh ny cho thy cc t sut t vong do bnh tim gim ti 70% trong 3 thp k va qua ti mt vi quc gia, bao gm c, Canada, Vng quc Anh v Hp chng quc Hoa K. Nhng trong cng mt thi gian, cc t l cc quc gia khc nhau v d nh Brazil v Lin bang Nga c th duy tr cng mt mc hoc tng.3 Bc tip theo trong iu tra s khc bit ny c th i hi thng tin v s so snh cc chng nhn t vong, cc thay i trong t l mi mc v t vong theo trng hp bnh, v nhng thay i v cc yu t nguy c m cc qun th lin quan b phi nhim.

Nghin cu sinh thi

Cc nghin cu sinh thi (hoc tng quan) rt hu ch cho vic hnh thnh gi thuyt. Trong mt nghin cu sinh thi, cc n v phn tch l cc nhm ngi hn l cc c th. V d, mt mi lin h c tm thy gia mc tiu th trung bnh ca thuc chng

44 Chng 3 hen v s xut hin mt s lng t vong v hen cao bt thng ti cc tnh khc nhau ca New Zealand.4 Quan st nh vy cn c kim nh bng vic kim sot tt c cc yu t nhiu tim tng loi b kh nng cc c tnh khc v d nh mc trm trng ca bnh ti cc qun th khc nhau khng phi l nguyn nhn ca mi quan h.

Hnh 3.2. Cc t sut t vong chun ho theo tui do bnh tim mch ca nam tui t 30 tr ln,319502002.

Cc nghin cu sinh thi cng c th c thc hin bng cch so snh cc qun th ti cc khu vc khc nhau trong cng mt thi im hoc, trong mt chui thi im, bng vic so snh cng mt qun th mt v tr ti cc thi im khc nhau. Mt v d l nghin cu sinh thi s dng s liu v sc khe ton th gii (xem Hp 4.2). So snh theo thi gian c th lm gim cc yu t nhiu v kinh t x hi, mt vn tim tng trong cc nghin cu sinh thi. Nu khong thi gian trong nghin cu so snh l rt ngn, nh trong cc nghin cu theo ngy (Hnh 3.3), yu t nhiu gn nh bng khng do con ngi trong nghin cu cng ng vai tr l i chng ca chnh h. Hnh 3.3: T vong trong t nng Pari, 20035

Cc thit k nghin cu 45 Mc d thit k n gin v v vy kh th v, cc nghin cu tng quan thng rt kh din gii do chng him khi c kh nng xc nh trc tip nhng gii thch tim nng khc nhau cho cc kt qu. Cc nghin cu tng quan thng da vo s liu thu thp cho cc mc ch khc; c th khng sn c cc s liu v cc phi nhim khc nhau v v cc yu t kinh t x hi. Thm vo , do n v phn tch l mt nhm, c th khng c mi lin h thc gia phi nhim v hiu qu tc ng mc c th. Mt iu hp dn ca nghin cu tng quan l s liu c th c s dng t cc qun th vi cc c tnh khc nhau nhiu hoc c ly t cc ngun s liu khc nhau. S gia tng t sut t vong trong t nng Php nm 2003 (Hnh 3.3) tng quan vi s tng nhit , mc d s tng nhim khng kh hng ngy cng ng mt vai tr quan trng. S tng t sut t vong ny ch yu xy ra nhng ngi gi v nguyn nhn trc tip ca t vong thng c ghi li l bnh tim hoc phi.

Ngu bin sinh thi

Ngu bin sinh thi hoc cc kt qu sai s l nhng kt lun khng ph hp c a ra t sai s ca s liu sinh thi. Sai s xy ra v mi quan h quan st c gia cc bin mc nhm khng nht thit th hin mi lin h tn ti mc c th (xem Chng 2). Mt v d ca ngu bin sinh thi c th hin trong Hnh 3.4, l khng c mi lin quan gia t vong m v tnh trng thiu ngi c k nng bn vng pha bn phi ca hnh. Nhng suy lun sinh thi nh vy, mc d c hn ch, cng c th cung cp mt bc khi u tt cho cc nghin cu dch t su hn v sau.

Hnh 3.4. T sut t vong s sinh v t vong m lin quan n s thiu k nng ca ngi .6

Nghin cu ct ngang
Nghin cu ct ngang o lng t l hin mc ca bnh v v vy thng c gi l nghin cu hin mc. Trong nghin cu ct ngang, cc o lng phi nhim v bnh c tin hnh cng mt thi gian. Vic nh gi cc nguyn nhn trong cc mi lin

46 Chng 3 h quan st c trong nghin cu ct ngang khng phi l d dng. Cu hi c bn c t ra l liu phi nhim c trc hay sau kt qu. Nu s liu phi nhim c bit l i din cho phi nhim c trc khi kt qu xy ra, s liu t mt nghin cu ct ngang c th c coi nh s liu t mt nghin cu thun tp. Nghin cu ct ngang thng d tin hnh v t tn km, hu ch cho iu tra cc phi nhim l cc c tnh c nh ca cc c th, v d nh dn tc hoc nhm mu. Trong cc v dch bnh bng n t ngt, mt nghin cu ct ngang o lng mt s yu t phi nhim c th l bc u tin thun tin nht trong iu tra cn nguyn. S liu t cc nghin cu ct ngang rt hu ch trong nh gi cc nhu cu chm sc y t ca cc qun th. S liu t cc iu tra nhc li s dng cc mu ngu nhin c lp vi cc nh ngha chun ho v cc phng php iu tra cung cp cc ch s hu ch ca cc xu hng.7,8 Mi iu tra cn c mt mc ch r rng. Cc iu tra c gi tr cn b cu hi c thit k tt, mt mu nghin cu ph hp vi kch thc ln, v mt t l tham gia cao. Nhiu quc gia tin hnh cc iu tra ct ngang thng xuyn trn mu i din cho cc qun th ca h, tp trung vo cc c im c nhn v dn s, bnh tt v cc thi quen lin quan n sc kho. T l bnh v cc yu t nguy c sau c th c xc nh trong mi lin quan vi tui, gii v dn tc. Cc nghin cu ct ngang v cc yu t nguy c ca bnh mn tnh c thc hin trn rt nhiu quc gia (Hp 3.1). Hp 3.1. C s d liu thng tin ton cu ca TCYTTG: mt cng c trc tuyn
C s d liu thng tin ton cu ca TCYTTG (http://infobase.who.int) l mt kho cha thng tin c thu thp, lu tr v hin th thng tin v cc bnh mn tnh v cc yu t nguy c ca cc tnh trng (tha cn/bo ph, cao huyt p, cholesterol, ung ru, ht thuc l, tiu th rau/hoa qu, cc hot ng th lc, tiu ng) ca 186 quc gia. C s d liu thng tin c thit lp vo nm 2002 ci thin vic tip cn ca cc chuyn gia y t v cc nh nghin cu vi s liu v cc yu t nguy c ca bnh khng truyn nhim. Cc la chn sau y hin sn c trn mng: so snh cc quc gia s dng cc c lng ca TCYTTG vi cc yu t nguy c to h s quc gia lu tr nhng s liu mi nht i din cho quc gia s dng mt cng c iu tra cho tt c cc s liu quc gia v cc yu t nguy c c bit

Nghin cu bnh chng

Nghin cu bnh chng cung cp mt phng php tng i n gin iu tra cc nguyn nhn ca bnh tt, c bit l cc bnh him. N gm nhng ngi c bnh (hay mt tnh trng sc kho) m ta quan tm v mt nhm chng ph hp (nhm so snh hoc tham chiu), gm nhng ngi khng mc bnh hoc khng c tnh trng sc kho quan tm. Nghin cu so snh s xut hin ca cc nguyn nhn c th trong cc trng hp bnh v cc trng hp chng. Cc nh iu tra thu thp s liu v s xut hin bnh ti mt thi im v cc phi nhim ti thi im trc . Cc nghin cu bnh chng l nghin cu dc, i lp vi cc nghin cu ct ngang (Hnh 3.5). Cc nghin cu bnh chng v ang c gi l cc nghin cu hi cu v nh nghin cu xem xt ngc li t bnh n nguyn nhn c th gy bnh. iu ny c th b nhm ln bi t hi cu v tin cu ngy cng c s dng nhiu m t v tin trnh thu thp s liu trong mi lin quan n thi im hin hnh. V vy nghin cu bnh chng c th l mt nghin cu hi cu khi tt c cc s liu c thu thp v qu kh hoc tin cu khi vic thu thp s liu tip tc tin trin theo thi gian.

Cc thit k nghin cu 47

La chn cc trng hp bnh v cc trng hp chng

Mt nghin cu bnh chng bt u bng vic chn cc trng hp bnh, cc trng hp ny nn i din cho tt c cc trng hp bnh trong mt nhm qun th xc nh. Cc trng hp bnh c la chn da trn tnh trng bnh ch khng phi tnh trng phi nhim. Cc trng hp chng phi l nhng ngi khng mang bnh. Kha cnh then cht v th thch nht ca cc nghin cu bnh chng da trn qun th l tm ra mt cch hiu qu v chi ph nht xc nh v tp hp cc trng hp chng.9 Nhim v kh khn nht l la chn cc trng hp chng sao cho i din v t l phi nhim cho qun th t sn sinh ra cc ca bnh. Hn na, s la chn cc trng hp chng v bnh khng c nh hng bi tnh trng phi nhim, tnh trng phi nhim phi c xc nh theo cch nh nhau cho c nhm chng v bnh. Khng nht thit phi ly tt c cc trng hp bnh v chng; trong thc t, c th gii hn bnh v chng trong bt k nhm nh c th no, chng hn nh ngi cao tui, nam gii hay n gii. Hnh 3.5: Thit k ca mt nghin cu bnh chng

Cc trng hp chng nn i din cho nhng ngi s c ch nh vo nghin cu trong nhm bnh nu nh h pht trin bnh. L tng, nghin cu bnh chng s dng cc ca bnh mi (mi mc) trnh s kh khn trong phn bit cc yu t lin quan n nguyn nhn gy bnh v s tn ti (hoc hi phc), mc d cc nghin cu c tin hnh thng s dng s liu hin mc (v d, cc nghin cu bnh chng v d tt bm sinh). Cc nghin cu bnh chng c th c lng nguy c tng i ca bnh, nhng khng th xc nh t l mi mc tuyt i ca bnh.

Phi nhim
Mt kha cnh quan trng ca nghin cu bnh chng l vic xc nh im bt u v khong thi gian phi nhim ca cc trng hp bnh v chng. Trong thit k bnh chng, tnh trng phi nhim ca cc ca bnh thng c xc nh sau khi bnh pht trin (s liu hi cu) v thng bng cch hi trc tip nhng ngi bnh hoc ngi thn (Hp 3.2). Cc cu tr li c th b nh hng bi kin thc v gi thuyt trong iu tra hoc kinh nghim bn thn v bnh tt.

48 Chng 3

Hp 3.2. Thalidomide
Mt v d in hnh v nghin cu bnh chng l nghin cu tm ra mi lin h gia thalidomide v d tt chn tay tr em sinh ra Cng Ho Lin Bang c trong nhng nm 1959 v 1960. Nghin cu thc hin vo nm 1961, so snh tr d tt vi tr bnh thng. Trong 46 b m c con b d tt in hnh, 41 ngi dng thalidomide trong khong t tun th 4 n tun th 9 khi mang thai, trong khi , khng c ai trong s 300 b m ca 10 chng, nhng ngi m con ca h sinh ra bnh thng, dng thuc trong thi k . Thi gian chnh xc ca vic ung thuc l im ch cht trong xc nh phi nhim lin quan.

Mt v d khc v s dng thit k nghin cu bnh chng c trnh by trong Bng 3.2. Cc nh nghin cu Papua New Guinea so snh tin s tiu th tht nhng ngi c bnh giun ch v tin hnh so snh vi nhng ngi khng b bnh. T l nhng ngi c bnh tiu th tht trc (50 trong tng s 61 trng hp) cao hn so vi nhng ngi khng mc bnh (16 trong s 57 ngi).11 Bng 3.2. Mi lin h gia vic tiu th tht gn y v bnh giun ch Papua New Guinea.
Phi nhim (tiu th tht) C Khng 50 11 16 41 66 52 Tng 61 57 118

Bnh (bnh giun)

C Khng Tng

Phi nhim i khi c xc nh bi cc o lng sinh ho (v d nh lng ch trong mu hay canxi trong nc tiu), n c th khng phn nh chnh xc tnh trng phi nhim tng ng trong qu kh. V d, lng ch trong mu lc 6 tui khng phi l mt ch s tt ca tnh trng phi nhim tui 1 2. Vn ny c th trnh c nu phi nhim c th c c lng t mt h thng bo co (v d, cc kt qu xt nghim mu nh k hoc cc h s tuyn dng c lu tr) hoc nu nghin cu bnh chng c thc hin tin cu, khi s liu phi nhim c thu thp trc khi bnh pht trin.

T s chnh
S kt hp gia mt yu t phi nhim v mt bnh (nguy c tng i) trong nghin cu bnh chng c o lng bng cch tnh t s chnh (OR), y l t s gia chnh ca phi nhim trong nhm bnh v chnh ca phi nhim trong nhm chng. Vi v d trong Bng 3.2, t s chnh c tnh nh sau:

OR = (50 / 11) (16 / 41) =

50 41 = 11,6 11 16

Kt qu ny cho thy so vi nhng ngi khng b bnh th nhng ngi b bnh gn y n tht nhiu gp 11,6 ln. T s chnh ny cng xp x bng t s nguy c, c bit nu l bnh him gp. t s chnh l mt c lng tt, cc trng hp bnh v chng cn i din cho qun th chung v tnh trng phi nhim. Tuy nhin, do t l mi mc ca bnh khng c bit, nn khng tnh c nguy c tuyt i. T s chnh cn i cng vi khong tin cy quan st c xung quanh c lng im (xem Chng 4).

Cc thit k nghin cu 49

Nghin cu thun tp
Nghin cu thun tp hay cn gi l nghin cu theo di hay nghin cu mi mc, khi u bng mt nhm ngi khng mc bnh, c chia thnh cc nhm nh ty thuc vo tnh trng phi nhim vi mt nguyn nhn gy bnh tim tng hay mt tnh trng sc kho (Hnh 3.6). Cc bin quan tm c c th ho v c o lng, v ton b nhm thun tp c theo di xem xt s pht trin ca cc ca bnh mi (hoc tnh trng sc kho) khc nhau nh th no gia cc c th c v khng phi nhim. V cc s liu phi nhim v bnh lin quan n cc thi im khc nhau, nn cc nghin cu thun tp l nghin cu dc, nh cc nghin cu bnh chng. Cc nghin cu thun tp c gi l cc nghin cu tin cu nhng thut ng ny d nhm ln v nn trnh. Nh bn lun trc y, thut ng tin cu cp n thi gian thu thp s liu ch khng phi mi lin h gia phi nhim v tnh trng sc kho. V vy, c th c c nghin cu thun tp tin cu v hi cu.

Hnh 3.6. Hng iu tra ca mt nghin cu thun tp

Thi gian Hng iu tra Bnh PhI nhim Khng bnh Qun th Ngi khng nhim bnh Bnh Khng phI nhim Khng bnh

Cc nghin cu thun tp cung cp thng tin tt nht v nguyn nhn ca bnh v cho php o lng nguy c pht trin bnh trc tip. Mc d n gin v mt l thuyt, nghin cu thun tp i hi thi gian theo di di v bnh c th xy ra mt thi gian di sau khi phi nhim. V d, giai on cm nhim ca bnh ung th bch cu hoc ung th tuyn gip do phng x (tc l thi k cn thit cho mt nguyn nhn c th no gy ra bnh) ko di trong rt nhiu nm v cn phi theo di cc i tng nghin cu trong mt thi gian di tng ng. Nhiu phi nhim din ra rt lu trn thc t v c cc thng tin phi nhim chnh xc v chng cn phi thu thp s liu trong nhng khong thi gian di. Tuy nhin, v d trong trng hp ht thuc l, nhiu ngi c thi quen ht thuc n nh mt cch tng i v thng tin v ht thuc trc kia v hin ti c th c thu thp ti thi im nhm thun tp c xc nh. Trong cc tnh hung phi nhim l cp tnh v t xut, th mi quan h nhn qu i vi cc tc ng cp tnh c th r rng, nhng cc nghin cu thun tp cng c s dng iu tra cc tc ng mun v mn tnh (Hp 3.3).

50 Chng 3

Hp 3.3. Tc ng mun ca ng c: Bhopal

Mt v d o lng tc ng lu di l v nhim c nghim trng i vi c dn sng xung quanh nh my thuc tr su Bhopal, n nm 1984.12 Mt ho cht trung gian trong qu trnh sn xut, methylisocyanate b r r t b cha v khi bc ln lan to ra cc khu dn c xung quanh, lm na triu ngi phi nhim vi kh ga. 20.000 ngi t vong v nhim c ny. Thm vo , 120.000 ngi vn phi chu nhng tc ng n sc kho gy ra do nhim. Cc tc ng cp tnh c nghin cu d dng bng thit k ct ngang. Cc tc ng mn tnh kh thy hn v cc tc ng ch pht trin sau mt thi gian di vn ang c cc thit k thun tp nghin cu.

V cc nghin cu thun tp bt u vi nhng ngi c phi nhim v khng phi nhim, nhng kh khn ca vic o lng phi nhim hoc tm kim nhng s liu hin c v tnh trng phi nhim ca cc c th c ngha quan trng trong vic quyt nh loi thit k no c th kh thi s dng. Nu bnh him trong nhm c phi nhim, cng nh nhm khng phi nhim th c th c kh khn khi mun m bo mt nhm nghin cu ln. Chi ph cho nghin cu thun tp c th gim i bng cch s dng cc ngun thng tin nh k v t vong v bnh tt nh cc h thng ghi nhn bnh tt, hay cc h thng ghi nhn t vong quc gia nh l mt phn ca quy trnh theo di. Mt v d l Nghin cu Sc kho ca cc Y t (Hp 3.4). Hp 3.4. Nghin cu sc kho ca cc Y t
Mc d chi ph l vn c bn trong cc nghin cu thun tp ln, cc phng php c pht trin lm chng tn km hn khi thc hin. Nm 1976, 121.700 y t n lp gia nh tui t 3055 hon thnh b cu hi ban u ca iu tra Sc kho cc Y t. C hai nm mt ln, b cu hi t in c gi n nhng y t ny, nhng ngi cung cp thng tin v cc hnh vi sc kho v sc kho sinh sn v lch s bnh tt ca h. Nhm thun tp ban u c ng k vi mc tiu nh gi cc tc ng sc kho ca vin ung trnh thai. Cc nh iu tra kim tra cc phng php ca h trn cc nhm nh ca mt thun tp ln hn, v thu thp thng tin v bnh t cc ngun s liu nh k.13 Bn cnh vic nghin cu mi lin h gia vin ung trnh thai v nguy c ung th bung trng v ung th v, h cng c th nh gi mi lin quan vi cc bnh khc trn nhm thun tp ny v d nh bnh tim mch v t qu, v mi lin h gia ht thuc v nguy c t qu nh trnh by trong Bng 2.3. Mc d t qu l nguyn nhn tng i ph bin dn n t vong, iu ny him khi xy ra ph n tr tui, v v vy mt nhm thun tp ln l iu cn thit.

Do cc nghin cu thun tp ly nhng ngi kho mnh lm khi im, c th xem xt nh gi nhiu tnh trng sc kho (tri vi nghin cu bnh chng). V d, nghin cu ca Framingham, nghin cu thun tp c tin hnh nm 1948, iu tra cc yu t nguy c ca nhiu bnh, bao gm c cc bnh tim mch, cc bnh ng h hp v cc ri lon c xng.14 Cc nghin cu thun tp c ln tng t cng c thc hin Trung Quc. Cc c im dn s hc c bn, tin s bnh tt, v cc yu t nguy c bnh tim mch chnh bao gm cao huyt p v trng lng c th c thu thp t mt mu i din gm 169.871 n ng v ph n tui t 40 tr ln vo nm 1990. Cc nh nghin cu lp k hoch theo di nhm thun tp ny trn c s nh k.15 Mt loi c bit ca nghin cu thun tp l nghin cu cc cp sinh i ging ht nhau, ni yu t nhiu v gen khc nhau gia nhng ngi phi nhim v khng phi nhim vi mt yu t c bit c th c loi b. Cc nghin cu nh vy

Cc thit k nghin cu 51 cung cp nhng bng chng tt v cc mi lin h nhn qu a dng ca cc bnh khng truyn nhim. H thng ng k sinh i ti Thu in l mt v d tt v ngun s liu c th c s dng tr li rt nhiu cu hi dch t hc.16

Nghin cu thun tp lch s

Cc chi ph c th gim khi s dng mt thun tp lch s (c xc nh trn c s cc h s ghi chp v cc phi nhim trc ). Phng php iu tra ny c gi l nghin cu thun tp lch s, bi v ton b s liu phi nhim v kt qu (bnh) c thu thp trc khi tin hnh nghin cu. V d, h s ca qun nhn phi nhim vi cht phng x nguyn t ti nhng ni th nghim bom nguyn t c s dng tm hiu vai tr cn nguyn c th ca bi phng x trong vic pht trin bnh ung th trong vng 30 nm qua.17 Loi nghin cu ny tng i ph bin vi cc nghin cu v ung th lin quan n phi nhim ngh nghip.

Nghin cu bnh chng lng thun tp

Thit k nghin cu bnh chng lng thun tp lm cc nghin cu thun tp tn km hn. Cc trng hp bnh v chng u c chn t mt thun tp xc nh, trong mt s thng tin v cc yu t phi nhim v nguy c c sn (Hnh 3.7). Cc thng tin b sung v cc trng hp bnh mi v chng, c bit l nhng trng hp c la chn cho nghin cu, c thu thp v phn tch. Thit k ny c bit hu ch khi vic o lng phi nhim l rt tn km. Mt v d ca nghin cu bnh chng lng thun tp c trnh by trong Hp 3.5. Hp 3.5. Nghin cu bnh chng lng thun tp v ung th d dy
xc nh tnh trng nhim Helicobacter pylori c lin quan n ung th d dy khng, cc nh iu tra s dng mt thun tp gm 128.992 ngi c tin hnh vo gia nhng nm 1960. n nm 1991, 186 ngi trong thun tp ban u mc bnh ung th d dy. Cc nh iu tra sau tin hnh mt nghin cu bnh chng lng thun tp bng cch la chn 186 ngi b ung th d dy lm cc ca bnh v 186 trng hp khc khng mc bnh t cng nhm thun tp lm nhm chng. Tnh trng nhim H. pylori c xc nh hi cu t cc mu huyt thanh c lu tr t nhng nm 1960. 84% nhng ngi ung th d dy v ch c 61% nhng ngi khng mc bnh b nhim trc vi H. pylori, 8 gi mt mi lin h dng tnh gia nhim H. pylori v nguy c ung th d dy.1

Hnh 3.7. Xc nh bnh v chng trong nghin cu bnh chng lng thun tp

52 Chng 3

Tm tt cc nghin cu dch t
Bng 3.3 tm tt nhng ng dng ca cc loi nghin cu quan st khc nhau v Bng 3.4 tm lc nhng u v nhc im cng nh kh nng xy ra cc loi sai s (s bn lun chi tit trong phn sau ca chng). Bng 3.3. Nhng ng dng ca cc thit k nghin cu quan st khc nhau
Sinh thi iu tra bnh him iu tra nguyn nhn him Kim nh nhiu tc ng ca nguyn nhn Nghin cu nhiu phi nhim v cc yu t quyt nh Cc o lng v quan h thi gian o lng trc tip s mi mc iu tra v cc giai on tim n di ca bnh ++++ ++ + ++ ++ Ct ngang ++ ++ Bnh chng +++++ ++++ +b +c +++ Thun tp +++++ +++++ +++ +++++ +++++

Ch thch: + ...+++++ ch cc mc ph hp khng ph hp b nu l tin cu (tng lai) c nu l quy m qun th Bng 3.4. Nhng u v nhc im ca cc thit k nghin cu quan st khc nhau
Sinh thi Xc sut ca Sai s chn Sai s nh li Khng theo di c Nhiu Thi gian Chi ph KPH KPH KPH Cao Thp Thp Trung bnh Cao KPH Trung bnh Trung bnh Trung bnh Cao Cao Thp Trung bnh Trung bnh Trung bnh Thp Thp Cao Thp Cao Cao Ct ngang Bnh chng Thun tp

KPH: khng ph hp

Dch t hc thc nghim

Can thip hay thc nghim i hi n lc tch cc lm thay i mt bin s trong mt hoc nhiu nhm ngi. iu ny c ngha l vic loi tr mt yu t trong khu phn n ung m ngi iu tra ngh rng yu t gy d ng, hay th nghim mt cch iu tr mi trn mt nhm bnh nhn c chn. Cc tc ng ca mt can thip

Cc thit k nghin cu 53 c o lng bng cch so snh tnh trng sc kho nhm thc nghim vi nhm i chng. V cc can thip c quy nh cht ch trong cc cng, nn vic xem xt kha cnh o c trong nghin cu c tm quan trng rt ln khi thit k cc nghin cu ny. Chng hn, khng mt bnh nhn no b t chi cch iu tr thch hp khi tham gia vo mt th nghim, v th nghim c a ra kim nghim phi chp nhn c vi hiu bit hin ti. S chp nhn tham gia ca tt c cc i tng nghin cu l iu cn thit trong hu ht mi hon cnh. Loi nghin cu thc nghim, thng l mt phng php iu tr mi cho mt tnh trng c th, c th di mt trong ba hnh thc sau: Th nghim phn b ngu nhin c i chng, th nghim thc a, hoc th nghim cng ng.

Th nghim phn b ngu ngu nhin c i chng

Mt th nghim phn b ngu nhin c i chng l mt th nghim dch t hc c thit k nghin cu hiu qu ca mt can thip. Cc i tng ca mt qun th nghin cu c phn b ngu nhin vo cc nhm can thip v nhm i chng, sau kt qu c nh gi bng cch so snh tnh trng sc kho u ra trong cc nhm. Thit k mt th nghim phn b ngu nhin c i chng c trnh by trong Hnh 3.8. m bo rng cc nhm so snh l tng ng, cc bnh nhn c phn b mt cch ngu nhin, ngha l c ch nh mt cch tnh c. Nu nh s la chn v phn b ngu nhin c thc hin tt trc , nhm chng v nhm iu tr s c th so snh c ti thi im bt u iu tra; bt c s khc bit no gia cc nhm u l s xut hin tnh c khng b nh hng bi cc sai s c thc hoc khng thc ca nh iu tra. Hnh 3.8. Thit k ca mt th nghim ngu nhin i chng

Th nghim thc a
Cc th nghim thc a, tri vi cc th nghim lm sng, gm nhng ngi kho mnh nhng gi nh l c nguy c; vic thu thp s liu c thc hin ti thc a, thng khng phi gm nhng ngi sng trong cc c s t thin m l trong qun th ni chung (Hnh 3.8). Do cc i tng khng c bnh v mc ch l

54 Chng 3 phng nga vic xut hin bnh c th xy ra vi tn s tng i thp, nn cc cuc th nghim thc a thng phc tp v hu cn vi chi ph tn km. Mt trong nhng th nghim thc a ln nht l th nghim vaccine Salk phng bnh bi lit, c tin hnh trn mt triu tr em. Phng php th nghim thc a c th s dng nh gi cc can thip nhm gim s phi nhim m khng nht thit phi o lng s xut hin bnh. V d, cc phng php bo v khc nhau khi tip xc vi thuc tr su c th nghim theo cch ny, v vic o lng hm lng ch trong mu ca tr em cho thy tc dng ca vic phng chng bng cch loi b s dng sn c ch trong nh . Cc nghin cu can thip ny c th c tin hnh quy m nh vi chi ph thp hn do chng khng lin quan n vic theo di trong thi gian di hoc o lng s xut hin bnh.

Th nghim cng ng
Vi loi th nghim ny, cc nhm iu tr l cc cng ng ch khng phi l cc c th. Th nghim ny c bit thch hp vi nhng bnh c ngun gc t iu kin x hi, v v vy cc can thip nhm vo hnh vi ca nhm. Bnh tim mch l mt v d th nghim cng ng, mc d cc vn v phng php khng d on trc c th ny sinh trong nhng th nghim can thip cng ng ln. (Hp 3.6). Hp 3.6. Th nghim Can thip Cng ng ti 5 thnh ph Stanford
D n 5 thnh ph Stanford bt u t nm 1978, l mt trong s cc nghin cu can thip cng ng c thit k lm gim nguy c qun th ca bnh tim mch. Cc nh nghin cu tin tng rng cch tip cn cng ng l cch tt nht cp n nguy c phc hp ln ca s gia tng nh nhiu yu t nguy c v s lin quan n mt vi hnh vi sc kho. Mc d mt s cu phn ca can thip chng minh hiu qu khi nh gi mc c th (v d, hiu qu ca thng tin i chng v cc chng trnh pham vi cng ng khc) l ln, nhng thay i ng k v yu t nguy c cng xy ra cc nhm chng. Mt phn ca vn c lin quan n nhng gii hn trong thit k. Tnh gi tr ni ti c tho hip bi s tht l ch c mt s t cc n v can thip c th c nghin cu chi tit y . Cc nh nghin cu cng lu ti nhu cu ci tin cc can thip gio dc v m rng cc cu phn mi trng v chnh sch y t trong tng cng sc kho.

Hn ch ca th nghim cng ng
Mt hn ch ca nghin cu ny l nu ch c mt s nh cng ng tham gia th vic phn b ngu nhin cc cng ng l khng thc t; cn c cc phng php khc m bo rng bt k s khc bit no tm ra khi hon thnh nghin cu c th quy cho tc ng ca can thip ch khng phi do bt k s khc bit no gia cc cng ng.19 Ngoi ra, kh m tch bit cc cng ng khi nhng thay i chung ca x hi c th xy ra khi can thip c tin hnh. Vi cc hn ch v thit k, c bit khi i din vi nhng ci ln khng mong i, rt kh khc phc nhng thay i ng k v yu t nguy c cc nhm chng. Kt qu l, thng kh c kh nng cho cc kt lun xc nh v hiu qu chung ca can thip cng ng.20 Hnh 3.9 trnh by mt th nghim cng ng, mt chng trnh chng lao ti nng thn Ethiopia. 2.132 cng ng vi tng dn s 350.000 ngi c phn b ngu nhin vo cc nhm can thip v nhm chng. Kt qu cho thy chng trnh lm tng kh nng pht hin bnh lao dng tnh (nhiu trng hp c pht hin hn trong 3 thng u) trong khi cc bin php iu tr vn duy tr trong 12 thng.

Cc thit k nghin cu 55

Sai s tim tng trong cc nghin cu dch t h c

Cc iu tra dch t hc nhm mc ch cung cp cc o lng chnh xc s xut hin bnh (hay tnh trng sc kho no ). Tuy nhin c nhiu nguy c sai s trong o lng. Cc nh dch t hc dnh nhiu n lc dnh cho vic lm gim thiu cc sai s ny cng nh nh gi tc ng ca cc sai s khng th loi b c. Sai s c th l ngu nhin hoc h thng.

Sai s ngu nhin

Sai s ngu nhin l s lch i, do ngu nhin, may ri, ca mt quan st trn mt mu so vi gi tr tht ca qun th, dn n s thiu chnh xc trong vic o lng s kt hp. C ba ngun sai s ngu nhin chnh: dao ng v mt sinh hc gia cc c th, sai s chn mu, v sai s o lng. Hnh 3.9. M hnh th nghim phn b ngu nhin cng ng vo nhm can thip v nhm chng21

Sai s ngu nhin khng th loi b hon ton c v chng ta ch c th nghin cu trn mt mu ca qun th. Sai s ngu nhin l nguyn nhn ca mt thc t l mt c mu nh khng th i din cho tt c cc bin ca qun th. Cch tt nht lm gim sai s chn mu l tng c mu ca nghin cu. S bin thin c th thng xy ra v khng o lng no l chnh xc tuyt i. Sai s o lng c th gim i bng cc cng cht ch, v bng cch to ra cc o lng c th cng chnh xc cng tt. Cc nh iu tra cn hiu cc phng php o lng ang c s dng trong nghin cu, v cc sai s m cc phng php ny c th gy ra. L

56 Chng 3 tng, phng th nghim c kh nng a ra tin cy v tnh chnh xc ca cc o lng ca h bng cc qui trnh kim sot cht lng cht ch.

C mu
C mu cn ln nghin cu c hiu lc thng k pht hin nhng khc bit c cho l quan trng. Cc cch tnh c mu c th c thc hin vi cng thc chun c cung cp Chng 4. Cc thng tin sau y cn thit trc khi thc hin tnh ton c mu: Mc ngha thng k yu cu pht hin mt s khc bit; Sai s chp nhn c, hoc kh nng b l tc ng tht; Mc nh hng ca cuc iu tra; T l bnh trong qun th; ln tng i ca cc nhm so snh. Trong thc t, kch thc mu thng c quyt nh bi cc yu t nh hu cn v ti chnh v lun phi cn nhc gia vic tng c mu v chi ph. T chc Y t Th gii cng xut bn hng dn thc hnh xc nh c mu trong cc nghin cu y t.22 Tnh chnh xc ca nghin cu cng c th c ci thin bng cch m bo rng cc nhm c c mu tng i thch hp. iu ny thng l mt vn trong cc nghin cu bnh chng khi cn quyt nh v s lng chng vi mi trng hp bnh. Khng th chc chn v t s l tng gia chng v bnh v n ph thuc vo chi ph tp hp cc trng hp bnh v chng. Nu cc trng hp bnh l him gp v cc trng hp chng l nhiu, s l hp l khi tng t s gia chng so vi bnh. V d trong nghin cu bnh chng v tc ng ca thalidomid (Hp 3.2), 46 tr em b bnh so snh vi 300 tr bnh thng. Tuy nhin, nhn chung t c quan im v vic chn nhiu hn 4 chng cho mi trng hp bnh. iu quan trng l m bo rng s tng ng tho ng gia bnh v chng khi s liu c s dng phn tch, v d nh v nhm tui hay tng lp x hi; nu a phn cc trng hp bnh v ch mt s t cc trng hp chng nhm tui cao, th nghin cu s khng c kh nng xem xt n yu t nhiu l tui.

Sai s h thng
Sai s h thng (hay sai lch) xy ra trong dch t hc khi cc kt qu nghin cu khc mt cch c h thng so vi cc gi tr thc. Mt nghin cu c sai s h thng nh c coi l c tnh xc thc cao. Tnh xc thc khng chu nh hng ca c mu. Cc ngun sai s h thng c th c trong dch t hc th rt nhiu v a dng; c hn 30 loi sai lch c xc nh. Cc sai lch chnh l: Sai lch do chn; Sai lch do o lng (hay phn loi).

Sai lch do chn hay sai s chn

Sai s chn xy ra khi c mt khc bit c h thng gia cc c tnh ca nhng ngi c chn vo nghin cu v cc c tnh ca nhng ngi khng c chn vo nghin cu. Sai s chn hin nhin xy ra khi nhng ngi tham gia t chn mnh vo nghin cu, c th do h khng kho hoc do h c bit lo lng v mt tnh trng phi

Cc thit k nghin cu 57 nhim no . V d, ngi ta bit r l nhng ngi chp nhn li mi tham gia nghin cu v nh hng ca ht thuc th khc vi nhng ngi khng chp nhn tham gia nghin cu v cc thi quen ht thuc ca h; nhng ngi khng tham gia thng l nhng ngi ht nhiu hn. Trong cc nghin cu v sc kho ca tr em cn c s hp tc ca cha m, sai s chn cngc th xy ra. Trong mt nghin cu thun tp v tr s sinh,23 t l theo di thnh cng trong 12 thng thay i ty thuc vo mc thu nhp ca cha m. Nu cc c nhn tham gia vn li trong nghin cu c nhng c tnh khc vi nhng ngi khng c la chn lc u, hoc nhng ngi b cuc trc khi nghin cu hon thnh, th nghin cu s a ra mt c lng sai lch v mi lin h gia phi nhim v tnh trng sc kho. Mt sai s chn quan trng na xy ra khi chnh bnh hay yu t iu tra lm cho ngi ta khng sn sng tham gia cho nghin cu. V d, trong mt x nghip m cng nhn phi nhim vi formaldehyde, nhng cng nhn b au mt nhiu thng t ri b cng vic hoc theo li khuyn ca thy thuc. Nhng cng nhn cn li t b nh hng hn v nu nghin cu ct ngang ni lm vic v mi lin quan gia phi nhim vi formaldehyde v bnh au mt rt c th b sai lch. Trong cc nghin cu dch t hc v bnh ngh nghip nh vy, sai s chn quan trng ny c gi l hiu ng cng nhn kho mnh. Cc cng nhn phi c sc kho thc hin cng vic ca h; nhng ngi m rt nng v b tn tt thng b loi khi mi trng lm vic. Tng t nh vy, nu mt nghin cu c thc hin thng qua vic khm sc kho ti mt trung tm y t v khng tin hnh theo di nhng ngi khng quay tr li, th cc kt qu sai lch c th ny sinh: nhng ngi b bnh nng c th nm nh h hay bnh vin. Tt c cc thit k nghin cu dch t hc cn phi ch n sai s chn ny.

Sai s o lng
Sai s o lng xy ra khi vic o lng cc c th hay phn loi bnh hoc tnh trng phi nhim khng chnh xc c ngha l khng o lng c ng ci cn o lng. C rt nhiu ngun sai s o lng v nhng nh hng ca chng cc mc khc nhau. V d cc o lng ho sinh hay sinh l thng khng bao gi chnh xc hon ton v cc phng th nghim khc nhau thng cho cc kt qu khc nhau trn cng mu xt nghim. Nu cc mu xt nghim ca nhm phi nhim v nhm i chng c phn tch ngu nhin ti cc phng th nghim khc nhau, th s c t kh nng xy ra sai s h thng ny hn l khi ton b cc mu t nhm phi nhim c phn tch trong mt phng th nghim v ton b cc mu trong nhm chng c phn tch trong mt phng th nghim khc. Mt dng sai s o lng c bit quan trng trong nghin cu bnh chng c gi l sai s nh li. Sai s ny xy ra khi c s nh li cc thng tin khc nhau gia cc trng hp bnh v chng; chng hn, cc trng hp bnh c nhiu kh nng nh tnh trng phi nhim trong qu kh tt hn, c bit nu tnh trng phi nhim c bit rng ri l c lin quan ti bnh ang nghin cu v d, khng tp th dc v bnh tim. Sai s nh li cng c th hoc lm lm tng thm ln ca s kt hp gia phi nhim v bnh nh nhng bnh nhn b bnh tim thng c nhiu kh nng nhn l trc y t tp th dc hoc c lng thp v ln ca s kt hp nu cc trng hp bnh c xu hng ph nhn tnh trng phi nhim trc y hn so vi cc trng hp chng. Nu sai s o lng xy ra tng t trong cc nhm c so snh vi nhau th hu nh lun dn n mt c lng thp v mnh thc s ca mi quan h. Hnh

58 Chng 3 thc sai s khng khc bit ny c th gii thch mt vi s khng nht qun gia cc kt qu nghin cu dch t hc khc nhau. Nu nh iu tra, nhn vin phng th nghim hoc ngi tham gia nghin cu bit c tnh trng phi nhim, kin thc ny c th nh hng n cc o lng v gy ra sai s quan st. trnh c sai s ny, cc o lng c th c thc hin theo cch lm m n hoc lm m kp. Mt nghin cu lm m n ngha l cc nh iu tra khng bit nhng ngi tham gia c phn loi nh th no. Mt nghin cu lm m kp ngha l c cc nh iu tra ln ngi tham gia u khng bit tnh trng phn loi.

Nhiu
Nhiu l mt vn quan trng khc trong cc nghin cu dch t hc. Trong mt nghin cu v s kt hp gia mt phi nhim vi mt cn nguyn (hay yu t nguy c) v s xut hin bnh, th nhiu c th xy ra khi mt yu t phi nhim khc tn ti trong qun th nghin cu v c lin quan ti c bnh v yu t phi nhim m nghin cu quan tm. Mt vn ny sinh nu nh yu t ngoi lai ny chnh bn thn n l mt yu t quyt nh hay l mt yu t nguy c i vi tnh trng sc kho c phn b khng ng u gia cc nhm nh c phi nhim. Nhiu xy ra khi cc tc ng ca hai phi nhim (cc yu t nguy c) khng c tch bit v v vy i n kt lun khng chnh xc rng tc ng quan st c l do mt bin ny ch khng phi mt bin khc gy ra. tr thnh mt yu t nhiu cn p ng hai tiu ch (Hnh 3.10). Nhiu ny sinh do s phn b khng ngu nhin ca cc yu t nguy c trong qun th ngun cng xy ra trong qun th nghin cu v v vy a n cc c lng sai lch v tc ng (xem Hp 3.7). Trong trng hp ny, c th xut hin sai s, nhng trn thc t n khng phi kt qu ca sai s h thng trong thit k nghin cu.25 Tui v tng lp x hi thng l cc yu t nhiu trong cc nghin cu dch t hc. Mt mi lin h gia huyt p cao v bnh mch vnh c th i din cho nhng thay i i cng nhau ca hai bin theo mc tng ca tui; tc ng ca yu t nhiu tim tng l tui cn phi c xem xt, v khi thc hin iu ny th ngi ta quan st thy huyt p cao thc s lm tng nguy c ca bnh mch vnh. Hnh 3.10. Nhiu: ung c ph, ht thuc l v bnh mch vnh tim

Cc thit k nghin cu 59

Hp 3.7. Yu t nhiu: kh kim sot

T nhiu (confounder) bt ngun t ting Latin confundere, ngha l trn ln nhau. Nhiu c th c mt nh hng rt quan trng, v thm ch c th thay i hng r rng ca mi lin h. Mt bin s c v nh mang tnh bo v, sau khi kim sot theo nhiu c th c xc nh l yu t c hi. Mi quan tm thng thy nht v nhiu l n c th to ra mi lin h nhn qu r rng m c th khng h tn ti trn thc t. mt bin s l mt yu t nhiu, bn thn n phi l mt yu t quyt nh s xut hin bnh (v d, mt yu t nguy c) v phi lin quan n phi nhim khi iu tra. V vy, trong mt nghin cu v phi nhim phng x radon v ung th phi, ht thuc l khng phi l mt yu t nhiu nu cc thi quen ht thuc l nh nhau trong nhm phi nhim vi radon v nhm chng.

Trong v d Hnh 3.10, nhiu c th gii thch cho mi lin h gia ung c ph v nguy c mc bnh mch vnh, do chng ta bit ung c ph c lin quan n ht thuc l v nhng ngi ung c ph c xu hng ht thuc nhiu hn nhng ngi khng ung. Mt iu cng c bit r l ht thuc l l nguyn nhn ca bnh mch vnh tim. V c th mi lin h gia ung c ph v bnh mch vnh ch phn nh mi lin h bit gia ht thuc l v bnh tim. Trong tnh hung ny, ht thuc l lm nhiu mi lin h gia ung c ph v bnh mch vnh, v ht thuc lin quan n ung c ph v l mt yu t nguy c thm ch cho nhng ngi khng ung c ph.

Kim sot nhiu

C mt vi phng php kim sot nhiu, c th giai on thit k nghin cu hoc trong giai on phn tch kt qu. Cc phng php thng c s dng kim sot nhiu trong giai on thit k mt nghin cu dch t hc l: Phn b ngu nhin Gii hn Ghp cp Trong giai on phn tch th nhiu c th c kim sot bng cch: Phn tng Lp m hnh thng k

Phn b ngu nhin

Trong cc nghin cu thc nghim, phn b ngu nhin l mt bin php l tng m bo rng cc bin nhiu tim tng c phn b ng u vo cc nhm c so snh vi nhau. Cc c mu phi ln trnh s khng phn b ngu nhin cc bin s ny. Phn b ngu nhin trnh c mi quan h gia cc bin nhiu tim tng v yu t phi nhim ang c nghin cu.

Gii hn
Gii hn c th c dng hn ch nghin cu nhng ngi c nhng c tnh c th. V d trong mt nghin cu v nh hng ca c ph n bnh mch vnh, nhng ngi tham gia nghin cu c th c gii hn nhng ngi khng ht thuc l, v vy loi b c nh hng tim tng do tnh trng ht thuc l.

Ghp cp
Ghp cp c s dng kim sot nhiu bng cch chn la nhng ngi tham gia nghin cu sao cho m bo rng cc bin nhiu tim tng c phn b ng

60 Chng 3 u vo 2 nhm c so snh vi nhau. V d, trong mt nghin cu bnh chng tm hiu v mi quan h gia tp th dc v bnh mch vnh, th mi mt bnh nhn c bnh tim c th c ghp cp vi mt trng hp chng cng nhm tui v gii tnh m bo rng nhiu do tui v gii tnh khng xy ra. Mc d ghp cp c s dng rt nhiu trong cc nghin cu bnh chng, nhng n li c th dn ti cc vn trong la chn cc trng hp chng nu cc tiu chun ghp cp qu cht ch hoc qu nhiu; iu ny c gi l ghp cp qu mc. Ghp cp c th tn km v mt nhiu thi gian, nhng ghp cp c bit c ch nu khng c s chng cho gia cc trng hp bnh v chng, chng hn nh cc trng hp bnh thng gi hn cc trng hp chng.

Phn tng v lp m hnh thng k

Trong cc nghin cu ln ngi ta thng kim sot nhiu giai on phn tch ch khng phi giai on thit k. Nhiu sau c th c kim sot bng phn tng, o lng mnh ca s kt hp trong tng tng thun nht v c nh ngha r rng theo bin nhiu. Nu tui l mt yu t nhiu, th mi lin h c th c o lng, gi s, trong cc nhm tui vi khong cch l 10 nm; nu gii tnh hay chng tc l mt yu t nhiu, th s kt hp c o lng ring r nam gii v n gii hoc trong cc nhm chng tc khc nhau. Cc phng php hin c th gip tng hp s kt hp chung bng cch a ra mt trung bnh c hiu chnh ca cc c lng tnh cho mi tng ring bit. Mc d vic phn tng n gin v mt khi nim v tng i d thc hin, nhng n thng b hn ch bi c mu nghin cu v n khng th ng thi kim sot c nhiu yu t. Trong trng hp ny m hnh thng k (phn tch a bin) c s dng c lng mnh ca s kt hp trong khi vn ng thi kim sot cho mt s yu t nhiu; rt nhiu cc k thut thng k hin c s dng phn tch (Chng 4).

Tnh gi tr
Tnh gi tr l mc m mt xt nghim c kh nng o lng ci m n d nh o lng. Mt nghin cu c gi tr nu cc kt qu ca n tng ng vi s tht; nghin cu khng c c sai s h thng, v sai s ngu nhin cng nh cng tt. Hnh 3.11 m t mi quan h gia gi tr tht v cc gi tr o lng mc gi tr v tin cy cao v thp. Vi tin cy thp nhng tnh gi tr cao th cc gi tr o lng phn tn, nhng trung bnh ca cc gi tr o lng th gn vi gi tr tht. Ngc li, tin cy cao (hay tnh lp li) ca cc o lng khng m bo tnh gi tr bi v cc gi tr c th khc xa vi gi tr tht. C hai loi tnh gi tr: ni ti v ngoi suy.

Cc thit k nghin cu 61 Hnh 3.11. Tnh gi tr v tin cy

Tnh gi tr ni ti
Tnh gi tr ni ti l mc m cc kt qu ca mt quan st l chnh xc cho mt nhm ngi c th c nghin cu. V d, cc o lng hm lng huyt sc t phi phn bit c chnh xc nhng ngi tham gia b thiu mu nh nh ngha trong nghin cu. Phn tch mu mt phng th nghim khc c th cho cc kt qu khc do sai s h thng, nhng nh gi v cc mi quan h vi bnh thiu mu, nh c o lng mt phng th nghim, c th vn c tnh gi tr ni ti. i vi mt nghin cu v bt k mc ch g u cn gi tr ni ti, mc d mt nghin c tnh gi tr ni ti c th khng c kt qu g bi v cc kt qu ca n khng th so snh c vi cc nghin cu khc. Tnh gi tr ni ti c th b e do bi cc ngun sai s h thng nhng c th c ci thin nh thit k tt v thn trng.

Tnh ngoi suy

Tnh ngoi suy hoc khi qut l phm vi m cc kt qu ca mt nghin cu p dng c cho nhng ngi khng thuc nghin cu (v d: cho cc phng th nghim khng lin quan n nghin cu). Tnh gi tr ni ti l cn thit, nhng khng th m bo, cho tnh khi qut v n d t c hn. Tnh khi qut i hi vic kim sot cht lng bn ngoi ca cc o lng v nhng phn on v mc m cc kt qu nghin cu c th ngoi suy c. iu ny khng i hi l mu nghin cu phi i din cho mt qun th tham kho. V d, bng chng v nh hng ca vic h thp lng cholesterol trong mu ca nam gii cng c lin quan n bng chng ca ph n, nhng n i hi phi c s phn on v tnh khi qut ca cc nghin cu trn nam gii. Tnh khi qut c h tr bi cc thit k nghin cu kim nh gi thuyt r rng trong nhng qun th c nh ngha r rng. Gi tr ngoi suy ca mt nghin cu c khng nh nu c kt qu tng t t cc nghin cu cc qun th khc.24

Vn o c
Vn o c lin quan n cc hnh ng v cc chnh sch l ng hay sai, cng bng hay khng cng bng. Tnh trng kh x v o c ny sinh thng xuyn trong thc hnh dch t v cc nguyn tc o c chi phi thc hnh dch t, cng

62 Chng 3 nh trong tt c cc hot ng ca con ngi. Cc hng dn tin hnh nghin cu chung v con ngi c tho lun trong Chng 11. Nghin cu v gim st l ch yu m bo cc nh iu tra y t cng cng khng c nhng hu qu khng ch nh nghim trng v c hi nh tng xy ra Bangladesh khi o v xy dng ging nc (Hp 3.8). Hp 3.8. Cc hu qu khng ch nh: arsenic trong ging khoan ti Bngladesh
Lp t v xy dng ging khoan ci thin tnh trng nc v v sinh ti nng thn Bangladesh trong vi thp k trc l mt phn quan trng trong kim sot bnh t v cc bnh ly truyn qua ng tiu ho. Mc d 95% dn s hin ti sng da vo ngun nc ngm ny nhng khng h c mt kim tra no v s lng vi khun, kim loi nng hoc cc ho cht c hi trong nhng giai on u tin. Ch n nm 1985 khi mt bc s a phng ti ty Bengal, n bt u ch n cc bnh nhn c nhng du hiu lm sng v nhim c arsenic (hnh thnh sc t da v tng t l cc loi ung th), cc ging khoan mi c kim tra. Hin ti c khong 30 triu ngi, mt phn t dn s ca Bangladesh ang s dng nc vi mc nhim arsenic cao. Tt c cc can thip c th lm gim lng arsenic trong nc (x l nc ti my bm, x l nc ti nh, x l nc trn quy m cng ng, bt kn nhng ging c hm lng arsen cao, v khoan ging su hn di mc nc c hm lng arsen cao) u tn km hoc i hi bo dng hoc gim st lin tc.25

Tt c cc nghin cu dch t hc cn c hi ng o c xem xt v chp thun (xem Chng 11). Cc nguyn tc o c p dng trong thc hnh dch t v nghin cu bao gm: ng thun tham gia B mt Tn trng quyn con ngi m bo tnh khoa hc

ng thun tham gia

Cn c s ng thun tham gia t do v t nguyn t cc thnh vin tham gia cc nghin cu dch t v h c quyn rt khi nghin cu vo bt c thi im no. Tuy nhin, s ng thun tham gia l khng thc t khi tip cn cc h s y t nh k. Trong nhng trng hp ny, cng nh khi nim trong bt k nghin cu no, cc nh dch t hc cn tn trng s ring t c nhn v tnh b mt ti bt c thi gian no. H c ngha v thng bo cho cng ng h ang lm g v ti sao, v chuyn nhng kt qu nghin cu cng nh nhng ngha ca chng n cng ng c lin quan. Tt c cc cng ca cc nghin cu dch t hc cn c np cho hi ng o c trc khi nghin cu bt u.

m bo tnh khoa hc
Tt c cc nh khoa hc u c tim nng c x theo cch khng ng nguyn tc, c l mt phn bi p lc thnh cng. Cc nh dch t hc cng c th c hnh vi khng ng nguyn tc. V d bao gm cc kt qu nghin cu r rng b mu thun li ch nh hng v cng b s liu ba t.28,29 Vic lm gim thiu cc hnh vi khng ng nguyn tc i hi s thn trng trong hi ng o c v s quan tm ch ti nh gi ca cc bi bo khc.30 Qu trnh o to v kinh nghim ca cc nh dch t hc cn bao gm nhng tho lun nghim tc v nhc li v nhng vn ny.

Cc thit k nghin cu 63

Cu hi
3.1 3.2 3.3 3.4 3.5 3.6 Hy cho bit cc ng dng v nhng nhc im ca cc thit k nghin cu dch t chnh? M t thit k ca nghin cu bnh chng v nghin cu thun tp xc nh mi lin h gia ch n nhiu cht bo v ung th i trng? Sai s ngu nhin l g v lm th no gim nh hng? Cc loi sai s h thng chnh trong cc nghin cu dch t l g v lm th no gim tc ng ca chng? Hy cho bit nguy c tng i (RR) v t s chnh (OR) c s dng trong nghin cu no? a ra cc l do ti sao chng c s dng trong mt nghin cu c th ny ch khng phi trong nghin cu khc. Mt nghin cu ct ngang v hi chng Down tm thy mi lin h vi th t sinh. C th c yu t nhiu no y v lm th no trnh c yu t nhiu?

64 Chng 3

Ti liu tham kho

1. Gottlieb MS, Schroff R, Schanker HM, Weisman JD, Fan PT, Wolf RA, et al. Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency. N Engl J Med 1981;305:142531. Medline 2. Hgberg U, Wall S. Secular trends in maternal mortality in Sweden from 1750 to 1980. Bull World Health Organ 1986;64:7984. Medline 3. Preventing chronic diseases: a vital investment. Geneva, World Health Organization, 2005. 4. Pearce N, Hensley MJ. Beta agonists and asthma deaths. Epidemiol Rev 1998;20:17386. Medline 5. Impact de la vague de chaleur. Paris, Institute de Veille Sanitaire, 2003. http://www.invs.sante.fr/publications/2003/chaleur_aout_2003/rap _chaleur_290803.pdf 6. World Health Report 2005: Make every mother and child count. Geneva, World Health Organization, 2005. 7. Tolonen H, Dobson A, Kulathinal S, Sangita A, for the WHO MONICA Project. Assessing the quality of risk factor survey data: lessons from the WHO MONICA Project. Eur J Cardiovasc Prev Rehabil 2006;13:10414. 8. Bonita R, Douglas K, Winkelmann R, De Courten M. The WHO STEPwise approach to surveillance (STEPS) of noncommunicable disease risk factors. In McQueen DV, Puska P eds. Global Risk Factor Surveillance. London, Kluwer Academic/Plenum Publishers, 2003:922. 9. Bernstein L. Control recruitment in populationbased casecontrol studies. Epidemiology 2006;17:2557. doi:10.1097/01.ede.0000209440.94875.42 10. Mellin GW, Katzenstein M. The saga of thalidomide. Neuropathy to embryopathy, with case reports of congenital anomalies. N Engl J Med 1962;267:123844. 11. Millar JS, Smellie S, Coldman AJ. Meat consumption as a risk factor in enteritis necroticans. Int J Epidemiol 1985;14:31821. Medline 12. Lapierre D, Moro J. Five past midnight in Bhopal. Warner Books, 2002. 13. Colditz GA, Martin P, Stampfer MJ, Willett WC, Sampson L, Rosner B, et al. Validation of questionnaire information on risk factors and disease outcomes in a prospective cohort study of women. Am J Epidemiol 1986;123:894 900.Medline 14. LloydJones DM, Leip EP, Larson MG, DAgostino RB, Beiser A, Wilson PW. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 2006;113:7918. doi:10.1161/CIRCULATIONAHA. 105.548206. 15. Chen Z, Lee L, Chen J, Collins R, Wu F, Guo Y, et al. Cohort Profile: The Kadoorie Study of Chronic Disease in China (KSCDC). Int J Epidemiol 2005;34:12439. doi:10.1093/ije/dyi174. 16. Lichtenstein P, De Faire U, Floderus B, Svartengren M, Svedberg P, Pedersen NL. The Swedish twin registry: a unique resource for clinical, epidemiological and genetic studies. J Intern Med 2002;252:184205. doi:10.1046/j.1365 2796.2002.01032.x. 17. Johnson JC, Thaul S, Page WF, Crawford H. Mortality Of Veteran Participants In The Crossroads Nuclear Test. Washington, National Academy Press, 1996. 18. Parsonnet J, Friedman GD, Vandersteen DP, Chang Y, Vogelman JH, Orentreich N, et al. Helicobacter pylori infection and the risk of gastric cancer. N Engl J Med 1991;325:112731. Medline

Cc thit k nghin cu 65 19. Fortmann SP, Flora JA, Winkleby MA, Schooler C, Taylor CB, Farquhar JW. Community intervention trials: reflections on the Stanford FiveCity Project Experience. Am J Epidemiol 1995;142:57686. Medline 20. Susser M. The tribulations of trialsinterventions in communities. Am J Public Health 1995;85:156. Medline 21. Shargie EB, Morkve O, Lindtjorn B. Tuberculosis casefinding through a village outreach programme in a rural setting in southern Ethiopia: community randomized trial. Bull World Health Organ 2006;84:1129. doi:10.2471/BLT.05.024489. 22. Lwanga SK, Lemeshow S. S ample size determination in health studies. Geneva, World Health Organization, 1991. 23. Victora CG, Barros FC, Vaughan JP, Teixeira AM. Birthweight and infant mortality: a longitudinal study of 5,914 Brazilian children. Int J Epidemiol 1987;16:23945. Medline 24. Grimes DA, Schulz KF. Bias and causal associations in observational research. Lancet 2002;359:24852. Medline 25. Smith AH, Lingas EO, Rahman, M. Contamination of drinking water by arsenic in Bangladesh: a public health emergency. Bull World Health 0rgan 2000;78:10933. 26. Pepper D. Bangladeshis poisoned by arsenic sue British organization. Lancet 2006;367:199200. doi:10.1016/S01406736(06)680161. 27. Zipperer M. HIV/AIDS prevention and control: the Cuban response. Lancet Infect Dis 2005;5:400. Medline doi:10.1016/S14733099(05)701511 28. Wikler D, Cash R. Ethical issues in global public health. In Beaglehole R, ed. Global Public Health: A New Era. Oxford, Oxford University Press, 2003. 29. Horton R. Expression of concern: nonsteroidal antiinflammatory drugs and the risk of oral cancer. Lancet 2006;3167:1961. doi:10.1016/S0140 6736(06)680148. 30. Gollogly L, Momen H. Ethical dilemmas in scientific publication: pitfalls and solutions for editors. Rev Saude Publica 2006;40:2430. Medline

67

Chng 4

Cc thng k sinh hc c bn: Cc khi nim v cng c

O. Dale Williams

Thng ip chnh
Dch t hc c bn cn c nhng kin thc v thng k sinh hc. Bng v biu , th l cng c tt cung cp thng tin, s liu. Cc khong tin cy c s dng nh nhng cng c c lng kim nh cc gi thuyt. Cc tnh ton c th phc tp, nhng cc khi nim ca kim nh thng k thng n gin.

Cc khi nim v cng c ca thng k sinh hc rt cn thit tng hp v phn tch s liu. Nghin cu dch t hc s dng cc kt qu t cc mu nghin cu suy lun cho qun th. Chng ny gii thiu mt s khi nim, phng php thng k c bn, cng nh qu trnh tng hp s liu. Chng 11 cung cp nhiu khung chng trnh, ti liu kho hc trc tuyn min ph phc v cho cc bn sinh vin mong mun tm hiu su hn v cc khi nim thng k sinh hc c bn ny. Trc khi m t nhng khi nim v cng c, chng ta cn lm quen vi nhng phng php khc nhau trong phin gii v truyn thng s liu. Chng ny s cung cp nhng phng php tng hp s liu thng dng nht; cc v d trong cc chng khc c s dng minh ho nhng nguyn l chung.

Tng hp s liu
S liu tn ti di hai dng: bin s hoc bin phn loi Cc bin s bao gm s m, v d nh s tr em ca mt nhm tui nht nh, cc o lng, v d chiu cao v cn nng. Cc bin phn loi l kt qu ca s sp xp. V d, cc c nhn c th c sp xp thnh cc nhm theo nhm mu ca h: A, B, O hoc AB. Cc s liu th hng - c th hin di dng thang bc - cng l mt dng ca s liu phn loi. S liu c tng hp bng cch s dng cc bng v th. S liu tng hp bao gm: trung v, trung bnh, khong, lch chun v phng sai. Cc khi nim ny s c m t chi tit hn di y vi nhng gi v lu v vic s dng nhng gi tr ny mt cch ph hp.

68 Chng 4

Cc bng v th
Cc bng v th l nhng cng c quan trng trong tng hp v trnh by s liu, nhng chng thng c chun b mt cch khng cn trng. Mc tiu ca bng v th l trnh by s liu mt cch d hiu v d s dng. Mi bng hoc th phi bao hm y thng tin ngi c c th hiu m khng cn cc ch gii. Hp 4.1. Nhng u im ca th v bng
u im ca th: n gin v r rng Hnh nh d ghi nh C kh nng trnh by nhng mi quan h phc tp th c a chung hn trong vic trnh by s liu so vi bng biu, bng chng l chng c s dng nhiu hn trn cc n phm thng thng so vi bng biu u im ca bng: Trnh by c nhiu s liu phc tp vi chnh xc v tnh linh hot cao Khng yu cu k nng cao v cc phn mm/thit b cao cp hon thnh bng Trnh by mt lng thng tin ln trn mt din tch nh

Tiu ng vai tr quan trng i vi th v bng biu. Tiu phi m t c th cc s liu c trnh by trong cc ca bng hoc cc im trn th. Vi cc bng, tiu phi ch r cc s liu trong cc biu th ni dung g, cc ny c phn loi nh th no, v a im, thi gian s liu c thu thp. Mt vn thng gp l tiu ca bng v th thng a ra mc tiu ch khng phi m t s liu m bng hay th trnh by. Cc nh dch t hc thng phi quyt nh trnh by s liu nh th no, s dng bng hay th. Mc d hai dng trnh by ny c nhiu im ging nhau, chng cng c nhng c th ring. Hp 4.1 s gip bn la chn bng hay biu cho vic trnh by kt qu nghin cu ca bn. C nhiu dng th khc nhau, di y l mt s dng hay c dng trnh by s liu v nhng hng dn s dng cc dng th ny. Hp 4.2. th sc kho th gii
th sc kho th gii (http://www.gapminder.org/) trnh by s pht trin sc kho th gii bng mt chui cc th tng tc lin kt vi s liu sn c. Nhng th ny c thit k khuyn khch hn na vic s dng s liu, bng chng ca nhng n lc ng h v h tr trong hnh thnh gi thuyt. Cc th trnh by m hnh ng, tng t nh cc tr chi trong my tnh. th sc kho th gii c th gip chng ta tr li mt s cu hi sau: Tnh trng sc kho v s thnh vng c mi lin h vi nhau nh th no trong qu kh? Th gii hin ti c kho mnh hn so vi tnh trng sc kho ca th gii ca 50100 nm trc? Tnh trng sc kho ca cc quc gia thay i khc nhau nh th no?

Cc thng k sinh hc c bn: cc khi nim v cng c 69

th hnh bnh v th cu phn hnh ct nm ngang

th hnh bnh (Hnh 7.1) v th cu phn hnh ct nm ngang (Hnh 6.2) hin th cc cu phn s liu so vi tng th. th hnh bnh trnh by s liu di dng hnh trn v th cu phn hnh ct nm ngang trnh by s liu di dng cc thanh nm ngang - c hai dng th ny u c chia thnh cc thnh phn nh, biu th s liu ca cc cu phn ring bit. Vi th hnh bnh, c mt qui c hu ch l t cc ming ca hnh trn theo kch thc ca chng, bt u im mi hai gi ri tip tc chuyn dch theo chiu quay ca kim ng h. Tuy nhin, so snh hai hay nhiu s liu bao gm cc cu phn so snh, chng ta nn s dng th cu phn hnh ct nm ngang v nu s dng th hnh bnh chng ta phi so snh cc ming ca hnh trn vi nhau.

Bn chm v bn t l
Hnh 4.1. S t vong do t trung tm London, thng 9-18546,7

Bn chm v bn t l trnh by s liu theo v tr a l. John Snow s dng loi bn chm ny trnh by a im ca nhng trng hp mc t cng vi

70 Chng 4 cc v tr ca nhng bm nc trong khu vc (Hnh 4.1). Bn t l hi khc vi bn chm ch, nhng khu vc a l c t l mi mc, hin mc, t l t vong khc nhau s c t m khc nhau. Nhng khu vc c t l cao nht s c t dm nht hoc mu sc sng nht (Hnh 4.2).

Hnh 4.2. T l t vong tr di 5 tui trn 1000 s tr sng cc nc chu phi, 20008

Bn , biu , th v tp bn /hnh v ngi c s dng trnh by s liu di hnh thc c nh nh Tp bn Sc kho Tm thn, Tp bn Thuc l, Tp bn Ung th v trnh by s liu di hnh thc tng tc (Hnh 4.2)

th hnh ct
th hnh ct c s dng hu ch nht khi ta mun so snh cc s lng hoc cc t l phn trm ca hai hay nhiu phn nhm khc nhau, nh t l nam v n ht thuc. Chiu di ca cc ct chuyn ti cc s liu c so snh, v vy nhng thay i hay bin ng ca chiu di cc ct do thay i cc thang o l thng khng ph hp trong v th ny so snh s liu (Hp 4.3).

Cc thng k sinh hc c bn: cc khi nim v cng c 71 Nu cc ct nm ngang (Hnh 2.3), th chng ta s c khong trng trnh by r rng nhn, hay tn ca cc ct. Trong mt s trng hp chng ta c th xp xp cc ct theo di ca chng. Hp 4.3. Nhng lu
Mc d khng ph hp, thang o ngt qung thng c s dng di nhiu hnh thc khc nhau. Thc t, cc thang o ny i khi c s dng a ra mi lin quan mt cch thn trng, v vic s dng ny thng da trn nhng kim tra k cng thang o trn trc tung. Khi c th ny, cn phi kim tra k trc tung m bo rng bn hiu r thang o c s dng v khng c nhng khong trng b che khut.

th hnh dy
th hnh dy (Hnh 6.1) c s dng tt nht trong trnh by s liu thay i ca cc bin lin tc, cc gi tr bin ny thng c biu th trn trc tung. V d s liu v mc cholesteron trong huyt thanh - c biu th trn trc tung - c th c chm bng cc im tng ng vi im thi gian trn trc honh. Mt im quan trng cn lu khi phin gii s liu trn th hnh dy l kim tra thang o ca trc tung. Nu thang o dng logit, phin gii s liu tuyt i phi tng ng vi t l c chuyn i. Vi dng th ny, thang o ngt qung c th c s dng trn trc tung, vi iu kin thang o ny phi c ghi ch r rng.

Phn b tn s v biu hnh ct

Phn b tn s l vic t chc s liu vo cc nhm k nhau trn trc s, nh vy s liu hoc t l quan st s ri vo mt trong cc khong s liu t ra. Nhng s liu ny thng c trnh by bng biu hnh ct, tng t nh th hnh ct nhng cc ct ng lin nhau, khng c khong trng gia cc ct (Hnh 6.7). Chiu cao ca ct trnh by s hoc t l phn trm quan st trong mi khong s liu. Hnh dng ca biu ny chuyn ti rt nhiu thng tin. a gic tn s, l ng ni im gia cc ct trong biu hnh ct, cng hay c s dng trnh by s liu. ng cong phn b chun l mt v d quan trng ca dng trnh by s liu ny (Hnh 4.3)

72 Chng 4

Cc phn b chun
Phn b chun c nhng c tnh rt hu ch. Hu ht cc kim nh v tnh ton thng k ch c th p dng phn tch cc s liu quan st c khi phn b ca cc s liu ny l phn b chun. Trong phn b chun, mt phn ba s liu s nm trong din tch c bao ph bi ng cong m gii hn hai pha l gi tr trung bnh cng tr mt lch chun v 95% s liu nm trong khong gii hn bi gi tr trung bnh cng tr hai lch chun.

Tng hp cc s liu
Trung bnh, trung v v mode
Mt tp hp cc i lng o lng tp trung, cc gi tr ny th hin c tnh cc gi tr trung tm ca cc mu o lng.

Trung bnh (mean)

Mt gi tr ni bt v rt ph hp trong o lng v tr trung tm l gi tr trung bnh ca mt mu, v d vi mt mu c n gi tr, vi bin xi = cn nng, gi tr trung bnh l: Trung bnh = x =

x
i =1

/n

Trung v (median)
Gi tr trung v l gi tr chnh gia cc o lng khi m cc gi tr o lng ny c xp xp theo trt t. Trung v rt c ch biu th v tr trung tm khi trong b s liu c mt vi gi tr qu ln so vi cc gi tr khc cn li. Vi l do ny, trung v ca cc thu nhp c nhn thng c s dng biu th v tr trung tm ca cc thu nhp c nhn hn l gi tr trung bnh ca cc thu nhp c nhn, v trung v s khng b tc ng bi thu nhp qu cao hn so vi cc i tng cn li ca mt s c nhn trong mu. Xin lu l mt s nc, thu nhp thng c thng bo l thu nhp bnh qun u ngi. Gi tr ny khc bit vi trung v ca thu nhp, l gi tr nm gia ca cc thu nhp c nhn, v cc gi tr ny thng biu th thu nhp trung bnh ca gia nh, trong khi thu nhp bnh qun u ngi quc gia l trung bnh thu nhp tnh theo dn s ca quc gia.

Mode
Mt n v quan trng khc l mode, gi tr c tn s xut hin cao nht trong tp hp cc quan st.

Phng sai, lch chun v sai s chun

Trong tng hp, o lng s liu, chng ta cn dng nhm ch s o lng s bin thin. C ba ch s o lng s bin thin hu ch l: Phng sai (variances) lch chun (standard deviations) Sai s chun (standard errors)

Cc thng k sinh hc c bn: cc khi nim v cng c 73 Cc gi tr ny lin quan ti vic biu din s bin thin ca nhng gi tr quan st o lng t cc mu khc nhau. Cc gi tr o lng s bin thin ny c th c tnh: Hiu s ca cc cp gi tr o lng trong mu hoc hiu s ca cc gi tr quan st vi trung bnh mu, v gi tr phng lch vi gi tr trung bnh. Vi tnh ton nh vy, kt qu s rt cng knh. Mt i lng khc tng ng c s dng thay th. Di y l cng thc n gin ho tnh phng sai ca mu:

( xi x ) 2 l bnh

x =

() 2 / n n 1
2

T s ca cng thc trn c th c vit di dng:

SS ( x) ( x x ) 2 = x 2 ( x) / n
Gi tr ny thng c gi l tng ca bnh phng cc lch so vi trung bnh, hoc n gin c vit di dng: Tng ca cc bnh phng = SS(x) Lu rng phng sai l xp x vi trung bnh ca bnh phng cc lch vi trung bnh. lch chun l kt qu ca cn bc hai ca phng sai hay s = s chun c tnh theo cng thc:

s 2 v sai

SE = s x = s / n
Gi tr ny thng c gi l sai s chun ca trung bnh. Sai s chun ca trung bnh phn nh s khc bit ca cc trung bnh mu, khi cc mu ny c chn li mt cch ngu nhin t cng mt qun th.

Cc khi nim c bn ca suy lun thng k

Qui trnh phin gii kt qu t mt mu iu tra cho qun th l mt kha cnh cc k quan trng ca cc nghin cu dch t hc. Nn tng ca suy lun thng k l t kt qu nghin cu ca cc mu c chn ngu nhin t qun th, nh nghin cu a ra nhng suy lun cho qun th chung. Nhng suy lun ny thng l cc suy lun cho cc gi tr: trung bnh, phng sai, hoc cc gi tr tng hp s liu khc. Cc s liu tng hp cho qun th c gi l cc tham s v c vit tt theo ch ci Hy Lp: = trung bnh = lch chun = h s hi qui

Cc c lng ca cc tham s ny thu c t cc mu nghin cu c biu th ln lt bng cc k t: x , s v b.

74 Chng 4

S dng cc mu suy lun v qun th

Cc mu ngu nhin
Qui trnh la chn mt mu t qun th l rt quan trng a ra cc suy lun thng k. Bc u tin l la chn mt mu ngu nhin, tc l mi c nhn ca qun th c xc sut ging nhau c la chn vo mu (xem Chng 3). Hin c nhiu chin lc v cc hng dn thc hin qui trnh mu ny. V d: tnh trung bnh mu 10 ngi c la chn t mt qun th v cn nng ca h theo ki l gam l: 82,3; 67,3; 68,6; 57,7; 67,3; 60,5; 61,8; 54,5; 73,2; v 85,9, trung bnh mu:

x =

x / n = 67,9 kg
i =1 i

Gi tr ny c s dng c lng trung bnh cn nng ca qun th (gi tr ). Nu chng ta la chn mt cch ngu nhin mt mu khc t qun th ny tnh trung bnh cn nng ca nhng ngi c chn vo mu mi, th trung bnh mu mi ny c th khc vi trung bnh trn, c th x = 68,2 kg, gi tr ny cng l mt c lng trugn bnh cn nng ca qun th (gi tr ). Khi nhng gi tr trung bnh mu ny khng c gi tr no tt hn gi tr no, s dn ti vic t ra cu hi lin quan ti tnh gi tr ca trung bnh mu, khi chng ta d dng chn mt mu khc tnh trung bnh mu x , t vn ny vo bi cnh ca qui trnh chn mu tnh ton ch s ny. Nu qui trnh chn mu c lp i lp li vi mt c mu ln theo thi gian, mt danh sch rt di ca trung bnh mu c th c a ra (Hp 4.4). xem tin cy ca trung bnh mu trong vic c lng trung bnh qun th nh th no, chng ta c th kim tra cc c im ca danh sch trung bnh mu ny. Nu trung bnh ca ton b cc trung bnh mu ny l ging vi trung bnh qun th, ngha l trung bnh mu a ra mt c lng trung bnh chnh xc v qun th.

Khong tin cy
Khong tin cy l mt trong nhng cng c hu ch nht trong dch t hc. nh ngha mt cch khi qut, xc nh khong tin cy l xc nh vng gi tr xung quanh gi tr trung bnh qun th, da vo thng tin t trung bnh mu. Gi tr ny c th c tnh ton mt cch d dng. Hp 4.4. Sai s chun ca trung bnh
iu l tng l nhng trung bnh mu s xp x nhau v xp x vi gi tr trung bnh qun th. lch chun ca cc trung bnh mu o lng xem cc gi tr trung bnh ny c tng t nhau hay khng c gi l sai s chun ca trung bnh. Lu rng danh sch cc trung bnh ca cc mu thc t l khng cn thit tnh sai s chun, sai s chun c th c tnh t mt lch chun ca mt trung bnh mu nh trong cng thc a ra.

Tnh ton khong tin cy

xc nh khong tin cy, chng ta cn tnh gii hn di v gii hn trn. Vi v d v cn nng, n = 10, x = 67,9, lch chun ca mu ny s = 10,2 kg. Gii hn di v gii hn trn c tnh l: Gii hn di = x ( 2,86) s / n = 67,9 2,68 *10,2 / 3,16 = 61,05

Cc thng k sinh hc c bn: cc khi nim v cng c 75 Gii hn trn = x + ( 2,86) s / n = 67,9 + 2,68 *10,2 / 3,16 = 78,35 C th vit kt qu khong tin cy di dng: C(61,05 < < 78,35) = 0,95 Gi tr ny ch ra r rng l 95% khong tin cy cho gi tr trung bnh qun th. di ca khong l 78,35 - 61,05 = 17,30 kg c th ln hn k vng. Lu l khong tin cy cng ngn cng tt, v vi c mu cng ln th khong tin cy cng ngn i. Trung bnh ca mu ( x ) lun thuc khong tin cy ny. Trong mt s trng hp, trung bnh qun th s nm chnh gia khong tin cy ny, hoc trung bnh qun th s nm trong khong tin cy ny, tuy nhin khng m bo chc chn l trung bnh qun th lun lun thuc khong tin cy c tnh ra t mu nghin cu ny.
Hp 4.5. Phin gii khong tin cy Trn thc t, c th c nhiu mu ngu nhin c chn ra t mt qun th v mi mu ngu nhin li cung cp 1 tnh ton v khang tin cy. Kt qu s c mt danh sch cc khong tin cy c a ra. Tuy nhin, nu chng ta chn = 0,05, khi 95% ca cc khong tin cy ny c cha gi tr trung bnh thc ca qun th v 5% l khng cha gi tr ny. iu hn ch l vi mt mu c th chng ta s khng bit c khong tin cy ca mu nghin cu ny s thuc nhm 95% hay thuc nhm 5%.

Bc t do
Lu l gi tr 2,68 c s dng trong cc tnh ton ny c ly t bng phn b t, vi n-1 = 9 bc t do. Tuy nhin, nu c mu n = 30, gi tr 2,00 s xp x vi gi tr a ra trong bng. Vi c mu rt ln, gi tr 1,96 s c s dng. Bng phn b ny c hu ht cc ti liu thng k chnh thng hoc c cc ngun ti liu thng k trn mng. V d ny ch trng vo khong tin cy cho ; tuy nhin, cc khi nim ny c s dng nhiu hn vi cc tham s khc, bao gm c cc ch s c tnh t phn tch hi qui v cho cc t sut chnh. Phin gii gi tr ny tng t nh phin gii c cp vi gi tr trung bnh. Phin gii khong tin cy c th i khi c mt s nhm ln (Hp 4.5).

Phin gii cc o lng ngoi khong tin cy

Khi phin gii cc khong tin cy, chng ta cn phi bit cch phin gii cho nhng gi tr nm ngoi khong tin cy. Trong v d v cn nng, s liu dao ng t 54,5 n 85,9 v khong tin cy 95% l t 60,61 n 75,19. Vy th liu c l khng khi cho rng gi tr trung bnh ca qun th l 80,0 kg. Khi chng ta k vng l 95% ca cc khong tin cy bao hm trung bnh qun th, th r rng trung bnh qun th s khng phi bng 80 kg, mc d l c th, khi khong tin cy ny thuc nhm 5% ch khng phi thuc nhm 95%. Tuy nhin, vn c mt s vn khi ni rng trung bnh qun th 80 kg, vn y l do chng ta t ngng = 0,05 a ra khong tin cy 95%. Mt iu quan trng l chng ta phi bit c nguy c khi ni rng 80 kg (khi thc t l 80 kg) c a ra do nh nghin cu ngi quyt nh a ra cch tnh khong tin cy. C nhng gi tr khc ngng = 0,05, c th c a ra p dng trong tnh khong tin cy, c th l = 0,01; tuy nhin gi tr ngng = 0,05 l thng c s dng nht v d dng c chp nhn. Hnh 5.2 a ra v d v mt khong tin cy.

76 Chng 4 Chng ta c th s dng khong tin cy kim nh gi thuyt, gi thuyt c th l: trung bnh cn nng qun th bng 80 kg. Trong trng hp ny, gi thuyt c kim nh v loi b gi thuyt da vo gii hn di v gii hn trn ca khong tin cy. Nhn chung, khong tin cy c th c s dng kim nh gi thuyt; tuy nhin, c nhiu phng php kim nh chnh thng hn c m t trong Hp 4.6.

Kim nh gi thuyt, gi tr p, lc thng k

Kim nh thng k lin quan ti tnh minh bch, r rng. Chng ta cn phi a ra nhn nh thn trng v gi thuyt c kim nh, gi tr p lin quan ti kim nh ny v lc thng k ca kim nh c s dng pht hin s khc bit ca ln.

Gi tr p
Trong v d trn, gi thuyt khng (H0) b loi b v cc quan st khc bit ln vi k vng a ra khi gi thuyt ny ng. Mc kim nh a ra l = 0,05. o lng chnh xc ca ngng khng xy ra cc kt qu ny, mt ln na c t di gi nh l gi thuyt ny l ng, c tnh ton sn. n gin l vng pha di 3,19 v vng trn +3,19 trong phn b t vi 9 bc t do. Vng pha di -3,19 l 0.011, vng trn +3,19 cng l 0,011 nh vy tng gi tr p = 0,022. Vng gi tr ny c gi l gi tr p, v gi tr ny biu th rng gi tr trung ca mu ngu nhin ca qun th ny c th l 67,9 hoc xa hn gi tr =80 kg. Nh vy, gi tr quan st c l rt him v nh vy kh c th tin rng =80 kg. Gi tr p v mc lin quan vi nhau kha cnh nu = 0,05, th gi thuyt H0 b loi b khi p < 0,05.

Lc thng k
Trong phn m t ca kim nh t hai mu di y, gi thuyt H0 l: H0 : 1 - 2 = 0 H1 : 1 - 2 0 dng kim tra hiu s ca hai trung bnh qun th. Nu hai trung bnh ny l cn nng ca qun th, khi trong bi cnh ny, hiu s ca hai trung bnh qun th cng ln, th cng c c hi loi b gi thuyt H0 khi s dng trung bnh mu.

Cc thng k sinh hc c bn: cc khi nim v cng c 77

Hp 4.6. V d: Kim nh gi thuyt

S dng v d trn, vi x = 67,9 kg, v s = 10,2 kg, qui trnh chun mc s l: Gi thuyt: Chng ta mun bit xem liu c th tin rng trung bnh qun th =80 kg hay khng. a ra kim nh tr li cho cu hi ny, chng ta la chn hai kh nng so snh: Gi thuyt khng : H0 : = 80 kg v i thuyt : H1 : 80 kg Kim nh thng k c a ra gip chng ta la chn c mt trong hai gi thuyt ny. i thuyt H1 c la chn khi chng ta ni rng gi thuyt H0 b loi b. Lu rng, i thuyt a ra H1 : 80 kg, bao gm c hai kh nng > 80 hoc < 80. iu ny ch ra rng, chng ta kim nh gi thuyt hai pha ch khng phi mt pha. Nhn chung, kim nh hai pha nn c dng cho cc ng dng dch t hc c bn, cng nh nhng iu kin a ra p dng kim nh mt pha l t khi xy ra. Cc gi nh: Trong trng hp ny, cc gi nh l mt mu ngu nhin c la chn t phn b chun. Nu c mu n ln hn hay bng 30, chng ta c th khng cn iu kin phn b chun. Mc : S dng = 0,05, tr khi c nhng yu cu cho mc kim nh khc. Mc kim nh khc thng c p dng l = 0,01. Kim nh thng k: Kim nh thng k tng ng vi vic s dng khong tin cy kim nh gi thuyt, cng thc kim nh t cho mt mu c trnh by di y. Cng thc ny s dng cc tham s ging nh vic tnh khong tin cy, nhng c t chc di hnh thc khc.

t=

x s/ n

Vng gii hn: Loi b gi thuyt H0 : = 80 kg khi gi th ca kim nh khng nm trong khong t0,975 (9) = 2,26. Lu rng iu ny m ch vng gii hn c phc ho bi cc im -2,26 v +2,26

Kt qu:

t=

69.7 80 = 3,19 10,2 / 10

Kt lun: Khi gi tr t tnh c khng nm trong khong t0,975 (9) = 2,26, ta c th kt lun l loi b gi thuyt H0 : = 80 kg. Khi chng ta s phin gii kt qu l trung bnh mu

= 67,9 rt khc bit vi gi tr trung bnh qun th = 80 kg. Vy i thuyt i

thuyt H1 : 80 kg c chp nhn, ngha l kh c th tin rng trung bnh thc ca cn nng qun th c th l 80 kg. Nh vy vi kt qu u ra

= 67,9, th mu nghin

cu ny s rt kh c kh nng c chn t qun th c trung bnh cn nng = 80 kg.

78 Chng 4 Mt cu hi quan trng na c th t ra l gi thuyt H0 c th b loi b khng nu hiu s gia hai trung bnh l 4 kg. Nh vy, kh nng pht hin c hiu s ca hai trung bnh l 4 kg nh th no? Kh nng pht hin ny c gi l lc thng k. D nhin lc thng k cng ln th cng tt vi chi ph c nh a ra cho nghin cu. Lc thng k b tc ng bi c mu (c mu cng ln cng tt) v phng sai ca cc quan st (phng sai cng nh cng tt), v vic thay i t = 0,05 ti = 0,01 cng s lm gim lc thng k. Khi thc hin kim nh cc gi thuyt, c th c nhng sai s xut hin. Nu gi thuyt H0 b loi b khi trong thc t gi thuyt ny ng, sai s ny gi l sai s , v tnh xc thc ca sai s ny da vo ngng c t ra trc khi thc hin kim nh. Thng thng chng ta a ra ngng = 0,05 cho cc kim nh, ngoi tr c nhng iu kin bt buc khc. Mt khc, khi chp nhn gi thuyt H0, mt sai s khc c th gp phi c gi l sai s . Sai s ny s c vit k hn trong phn c mu. Kh nng ca mt gi thuyt H0 b loi b ng vi thc t c gi l lc thng k v gi tr ny bng 1 xc sut ca sai s loi II (). Cc kh nng ca kt qu kim nh gi thuyt bao gm:
Kt qu kim nh Chp thun H0 Loi b H0 NG Sai s loi I hoc sai s Thc t H0 ng H0 sai Sai s loi II hoc sai s NG

Cc phng php kim nh c bn

Cc phng php kim nh c bn cho dch t hc bao gm: Kim nh t Kim nh Khi bnh phng (2) Tng quan Hi qui

Kim nh t
Thng thng trong dch t hc, chng ta c hai mu i din cho hai qun th khc nhau v chng ta mun tr li cu hi l: Hai trung bnh mu ny c thc s khc nhau chng ta c th kt lun hai trung bnh ca hai qun th l khc nhau? Kim nh t s dng thut ton thng k l: trong gi thuyt H0, hai trung bnh mu ny khc nhau c ngha thng k hay khng. Kim nh t c bit ph hp cho kim nh hai mu. Gi thuyt a ra l: H0 : 1 - 2 = 0 H1 : 1 - 2 0 c kim nh bng kim nh t, vi (n1 + n2 - 2) bc t do:

t=

2 x1 x2 (n1 1) s12 + (n2 1) s 2 , trong s 2 p = (n1 1) + (n2 1) 1 1 + sp / n1 n2

Cc thng k sinh hc c bn: cc khi nim v cng c 79

Kim nh Khi bnh phng cho bng cho

Bng cho hay bng tip lin l cng c trnh by s liu phn loi theo hai hay nhiu yu t, bin s khc nhau. Bng 3.4 l mt v d in hnh, bng hai nhn hai hay bng r x c, vi r = 2 hng, v c = 2 ct. Bng s liu ny trnh by s kt hp gia hai phi nhim v hai phn loi v tnh trng bnh tt. Bng s liu ny c th dng tr li cu hi : liu c bng chng no chng t c s kt hp gia phi nhim v mc bnh, v vy cn phi kim nh gi thuyt: H0: Khng c s kt hp no gia phi nhim v mc bnh ny H1: C s kt hp gia phi nhim v mc bnh ny Vi bng 2 x 2, gi thuyt ny c th dng so snh hai t l. Trogn trng hp ny, hai t l so snh l: PE = t l ca nhng ngi c phi nhim c pht trin bnh PNE = t l ca nhng ngi khng phi nhim c pht trin bnh Nh vy gi thuyt c th c a ra di dng l: H0: PE = PNE H1: PE PNE kim nh gi thuyt ny, chng ta so snh tn sut quan st O trong mi vi tn sut k vng E, nu gi thuyt H0 hon ton ng, E c th c tnh: (Tng hng) x (Tng ct) E= Tng ca bng Tng ca ct cui cng trong bng l gi tr ca 2(1), y l k hiu ca kim nh Khi bnh phng, vi mt bc t do. Bc t do c k hiu l df v df = (r-1)x(c-1). Kt qu tnh trong bng l 34,72, gi tr ny ln hn rt nhiu gi tr Khi bnh phng tra bng mc = 0,05 (bng 3,84); nh vy chng ta c th loi b gi thuyt H0. Bng gi tr Khi bnh phng sn c cc ti liu thng k trc tuyn hoc cc ti liu thng k chnh thng (xem Chng 11).
1 2 3 4 O 50 11 16 41 E 34,12 26,88 31,88 25,12 O-E 15,88 -15,88 -15,88 15,88 (O-E)2 252,22 252,22 252,22 252,22 (O-E)2/E 7,39 9,38 7,91 10,04

Tng cng

118

118

34,72

Tng quan
Hp 4.7. Phin gii mi lin quan gia hai bin s
Mt vic rt hu ch l kim tra mi lin quan gia hai bin s di dng hnh nh vi biu chm (xem Hnh 1.1). Biu chm vi cc im ti nhiu v tr hoc cc im dc theo ng cong th phn nh rng h s tng quan ny khng biu th rng hai bin s l c mi lin quan vi nhau.

Tng quan nh lng mc m hai bin s cng bin i (Chng 5). Nu hai bin s l c lp, gi tr ca mt bin s khng c mi lin quan vi bin cn li. Nu hai bin c mi lin quan, khi gi tr ca mt bin s lin quan ti gi tr ca bin cn li,

80 Chng 4 c th l cao khi gi tr bin kia l cao hoc ngc li gi tr ca bin ny l thp khi gi tr bin kia l cao. C nhiu cng c khc nhau o lng mi tng quan, Cng c thng dng nht l H s Tng quan bi Pearson, h s ny c tnh theo cng thc:

rxy =

xy ( x)( y) / n [ x ( x) / n ][ y ( y )
2 2 2

/ n]

SS ( xy) SS ( x) SS ( y )

H s ny o lng tng quan tuyn tnh, v c phm vi gi tr gia - 1 v +1 (1<r<+1). Gi tr ny s gn vi +1, khi mi tng quan tuyn tnh ny dng tnh mnh v gn vi -1 khi mi tng quan tuyn tnh ny m tnh mnh, v vy vi gi tr x nh th khi gi tr x c xu hng l ln. Khi r = 0, khng c mi tng quan tuyn tnh gia hai bin s. Nhng lu v vn ny c trnh by trong Hp 4.7.

Hi qui
S dng v phin gii cc m hnh hi qui
Cc m hnh hi qui l mt cng c quan trng trong phn tch s liu v hay c s dng trong cc nghin cu dch t hc. Cc khi nim ca m hnh hi qui khng phc tp, mc d vic tnh ton ch s ca m hnh ny l rt phc tp. Rt may mn l hin nay cc chng trnh phn mm tin hc hon ton c th thc hin cc tnh ton ny mt cch thun tin. Do vic tnh ton phc tp nn chng ti khng cp trong ti liu ny, m ch ch trng vo vic s dng v phin gii cc m hnh ny.

Cc m hnh hi qui khc nhau

C ba dng m hnh hi qui c bn c s dng trong nghin cu dch t hc l: Hi qui tuyn tnh Hi qui logic Hi qui Cox hazard, mt dng ca phn tch sng

Khi nim c bn ca cc m hnh hi qui

s dng cc m hnh ny, chng ta gi nh rng cc bin s c nh hng ln nhau. V d, chng ta c th cho rng cn nng ca mi ngi b nh hng bi tui hoc gii tnh. Gi tr quan tm l bin ph thuc (v d, cn nng) v cc yu t nh danh l cc bin c lp. Cc bin ph thuc trong m hnh l yu t phin bit cc m hnh vi nhau. Cc m hnh hi qui tuyn tnh. bin ph thuc l bin lin tc vi phn b l phn b chun. Cc m hnh hi qui logic. bin ph thuc l bin biu th c hoc khng c mt c tnh, c hai gi tr l 0 hoc 1. M hnh hi qui Cox hazard. bin ph thuc l bin biu th thi gian t khi bt u theo di cho ti khi xut hin kt qu/s kin k vng ca qu trnh theo di.

Phn tch sng - nh c thc hin trong m hnh hi qui Cox hazard - cng l mt cu phn b sung cn phi lu tm ti trong phn tch s liu.

Cc thng k sinh hc c bn: cc khi nim v cng c 81

Hi qui tuyn tnh

Chng ta c th s dng hi qui tuyn tnh p dng vo nhiu tnh hung khc nhau, t Phn tch phng sai chun tc (ANOVA), ti phn tch hi qui tuyn tnh n thun, v phn tch hi qui a bin. Trong ton b cc phn tch ny, bin ph thuc l bin lin tc (v d cn nng c th) v cc bin ph thuc c th bao gm c bin lin tc v bin phn loi

Bin ph thuc
M hnh in hnh vi bin ph thuc l y v k bin c lp c biu din di dng:

y = 0 + 1 x1 + 2 x2 + ... + k xk +
Trong : y = Bin ph thuc (v d, cn nng) 0 = im ct hoc yu t chia i = H s ca bin c lp xi xi = Gi tr ca bin c lp xi = Gi tr hng nh khng tnh m ti cc yu t khc. Gi tr ixi biu th cu phn ca cc bin c lp lin quan ti hoc ng gp cho bin ph thuc, y = cn nng c th; v d nh bin xi = tui. biu th cu phn cn li khi ton b cc cu phn khc c tnh m, v i khi gi tr ny lin quan ti khi nim sai s. Khi thc hin qui trnh ny, chng ta c th cho rng cn nng ca mi c nhn do nhiu cu phn qui nh, mi cu phn ny c biu th bng mt bin s c lp, cng vi hai cu phn khc - bao gm im ct 0 v gi tr cn li - . R rng, nhng cu phn b b qua cng nhiu th cng tt, vi ngha l m hnh gii thch r rng hn. Chng ta c th nh lng tnh hu ch ca mt m hnh hi qui c th bng cch tnh t l ca tng cc phng sai ca bin ph thuc c tnh m n theo cng thc hi qui: R2 = SS (M hnh) SS (Y)

Cc bin c lp
Nu bin c lp l bin lin tc, v d bin xi = tui, khi vic phin gii i l trc tip v biu th s thay i tng ln ca bin ph thuc. Y = cn nng ca c th, lin quan ti thay i ca xi = tui, hiu chnh cho ton b cc yu t t khc trong m hnh. iu ny ging nh khi nim v dc trong hi qui tuyn tnh n thun, v vy nu tui = 2 kg, phin gii ca chng ta s l: cn nng ca c th s tng ln 2 kg sau mi mt tui tng ln, c hiu chnh cho ton b cc yu t khc trong m hnh. Vi cc bin ph thuc l bin phn loi, phin gii s c s khc bit v cn phi thn trng. Mt v d in hnh l bin c lp v gii, gi tr x1 = 1 nu l nam gii v x1 = 0 nu l n gii. Trong trng hp ny, nhm gi tr x1 = 0 thng c gi l nhm tham chiu, so snh vi nhm c gi tr x1 = 1. Vi m hnh hi qui tuyn tnh, h s c tnh l: 1 = nam - n

82 Chng 4 Nh vy, hiu s gia hai trung bnh cn nng, nam - n, c hiu chnh cho ton b cc yu t khc trong m hnh.

a bin
Khi chng ta c t ba phn loi tr ln, tnh hnh s phc tp hn; vn ny cng hay xy ra v vic phin gii ng l rt quan trng. V d v phn loi ca nhm mu vi ba nhm mu l A, B, v O. Vi thc t ny, chng ta cn c hai bin c lp - nh hn s phn loi l mt. Trong trng hp ny, nhm tham chiu l phn loi O v nhng gi tr ca cc bin l: 1 = A - O 2 = B - O y, 1 l hiu s ca gi tr trung bnh trong nhm mu A tr i gi tr trung bnh trong nhm mu O, c hiu chnh cho ton b cc yu t khc trong m hnh. Vi cng thc ny, chng ta c th so snh trc tip A v O, B v O, nhng khng th so snh trc tip A v B. Chng ta phi c nhng gi tr khc nhau cho x1 v x2 so snh A v B. Cng thc trn lin quan ti gi tr qun th m c lng chng ta c th thu c t vic t m hnh vo mt b s liu c th. Bc u tin kim nh gi thuyt lin quan ti ton b cc gi tr , chng ta c th kim nh: H0: 1 = 2 = ... = k = 0 Nu gi thuyt ny b loi b, c bng chng l t nht mt gi tr khc khng, nh vy hon ton hp l khi tin hnh kim nh v cc h s i vi cc bin n l. Nu khng c gi tr no khc khng, khi khng c yu t no trong m hnh c ngha v v vy m hnh ny c t gi tr. Nhm mu A B O x1 1 0 0 x2 0 1 0

Hi qui logic
Trong cc v d trn, gi tr ca bin ph thuc l cn nng c th, v l bin lin tc. Chng ta c th quan tm ti cc yu t no c kt hp vi tnh trng bo ph hoc khng bo ph, tnh trng bo ph c nh ngha l nhng ngi c ch s khi c th (BMI) ln hn hoc bng 30. Phng php phn tch hi qui logic l mt cng c rt tt kim tra s kt hp ny. Kt qu k vng l t sut chnh v chng ta so snh s chnh lch ny. (V d, so snh tnh trng bo ph ca nam vi n), c hiu chnh cho cc yu t khc. M hnh hi qui logic s c trnh by di y l ti u nht cho mc tiu ny. M hnh hi qui da vo ln(chnh) bin ph thuc, trong ln l logarit c s e v chnh c nh ngha l thng s ca xc sut s xut hin s kin (p) chia cho xc sut khng xut hin s kin (1-p), thng c vit di dng: Chnh = p/(1-p) Nh vy m hnh s tr thnh: ln(chnh) = 0 + 1x1 + 2x2 + ... + kxk +

Cc thng k sinh hc c bn: cc khi nim v cng c 83 Hoc tng ng vi: Chnh = e0 + 1x1 + 2x2 + ... + kxk + Trong , xi c nh ngha nh trong m hnh hi qui tuyn tnh. phin gii h s ca cc m hnh ny, chng ta cn trng tm vo gi tr chnh v t sut chnh ch khng phi trng tm vo gi tr trung bnh, nh c cp trong m hnh hi qui tuyn tnh. V d, trong m hnh vi bin c lp x1=gii, v d x1=1 vi nhng ngi l nam gii v x1=0 vi nhng ngi l n gii, khi h s 1 c s dng trong cng thc: e1 = ORNam/N kt qu c phin gii l t sut chnh gia tnh trng bo ph ca nam v n, c hiu chnh cho cc bin khc trong m hnh. Ch s e1, c c t kt qu phn tch s liu l mt c lng ca t sut chnh ny. Vi bin c lp x2=tui, c o lng theo nm, khi phin gii s liu cho bin ny tng t nh phin gii dc trong m hnh hi qui tuyn tnh. e2= ORcho mi nm tng ln Nu ORtheo mi nm tng ln c hiu chnh bng 1,2, khi chnh ca bo ph s tng ln 20% cho mi nm tui tng ln, c hiu chnh cho cc yu t khc trong m hnh. Nu ORtheo mi nm tng ln c hiu chnh bng 0,75, khi chnh ca t l bo ph ca nm tip theo s bng 75% ca t l bo ph trong nm ngay trc , c hiu chnh cho cc yu t khc trong m hnh.

Phn tch sng v m hnh hi qui Cox hazard

Trong nhiu tnh hung, chng ta cn phi theo di i tng lin tc cho ti khi cc s kin xut hin (xem Hnh 8.4). Vi v d bo ph nu trn, gi s rng nhm bnh nhn c iu tr khi bo ph hon ton v h c theo di sau iu tr nh gi cc yu t lin quan ti vic mc li bo ph ca h. Trong trng hp ny, chng ta phi theo di h trong khong thi gian t khi kt thc iu tr cho ti khi h li b bo ph. M hnh hi qui Cox hazard l ph hp trong thc hin kim nh ny. Bin ph thuc l khong thi gian ti khi b bo ph tr li. Cc bin c lp trong m hnh tng t nh cc bin trong v d ca m hnh hi qui logic, cng thc hi qui l: h(t) = h0(t)e1x1 + 2x2 + ... + kxk Trong : h(t) = nguy c xut hin s kin, tn ti ti thi im t m s kin khng xut hin h0(t) = t l nguy c nn

84 Chng 4

Hp 4.10. Kim duyt

Kim duyt (censoring) l bin php x l thi gian theo di khi s kin quan tm khng xy ra trong thi gian theo di. Kim duyt cn thc hin do s mt i tng hoc cc l do dn ti mt theo di, cng c th lin quan ti mt s thnh vin tn ti trong sut khong thi gian theo di m khng xut hin s kin theo di. Thi gian theo di cho mt c nhn c t ra kim duyt, v d 15 thng, nu ngi khng xut hin s kin sc kho quan tm trong 15 thng theo di hoc ngi b mt theo di hoc nghin cu kt thc ti thi im . Mt khc, m hnh ny c s dng nh m hnh hi qui logic, ngoi tr vic m hnh ny cung cp c lng cho t sut nguy c hoc nguy c tng i thay cho t sut chnh, V vy, vi bin ph thuc x1 l gii, vi nam gii x1 = 1, n gii x1 = 0, khi h s 1 c s dng trong cng thc:

e1= RRnam/n Lu rng khng c 0 l im ct nh trong t l nguy c nn h0(t). C mt vn phc tp ca m hnh ny l chng ta cn phi tnh m n vic khng theo di c i tng nghin cu (Hp 4.10). Kt qu c phin gii l nguy c tng i ca bo ph gia nam v n c hiu chnh vi cc yu t khc trong m hnh. Ch s e1 thu c t kt qu phn tch l c lng ca nguy c tng i. Vi bin c lp x2 l tui, o lng theo nm, khi phin gii s liu cho bin ny tng t nh dc ca hi qui tuyn tnh: e2= RRcho mi nm tng ln Phin gii ca kt qu tng t nh t sut chnh trong v d v hi qui logic nu trn.

ng cong Kaplan-Meier
Cc ng cong s sng Kaplan-Meier thng c s dng trnh by s liu v s sng (xem Hnh 8.4). Chng c th c s dng trnh by bt k mt dng s liu v s kin-thi gian. Nu s kin chng ta quan tm l t vong, khi trc tung c s dng trnh by t l ngi cn sng ti mt thi im, cn trc honh biu th thi gian. Nhng t l ny chy trong khong t 1,0 vo im bt u v gim dn xung 0,0, nu ton b cc thnh vin ca nhm u t vong trong thi gian theo di. ng cong Kaplan-Meier rt r rng, d v, v d phin gii. Mt vn phc tp duy nht l vic kim duyt nh cp trn. Kaplan v Meier gii quyt vn ny, v vy ng cong ny c tn l ng cong Kaplan-Meier. Gii php ca h l v ng cong vi thi gian sng trn trc honh khng theo lch thi gian. S dng thi gian theo di lm tham chiu, h gi nh l mi c nhn c kim duyt 15 thng s sng cho ti khi c s kin tip theo xut hin trong khong thi gian theo di. Nh vy, h cho php c nhn ny sng mt khong thi gian hi di hn

Cc thng k sinh hc c bn: cc khi nim v cng c 85

Cc vn v c mu
Mt trong cc vn chng ta thng gp phi trong cc iu tra dch t hc l xc nh xem c mu ln nh th no c th tr li c cu hi nghin cu a ra. C mu ca nghin cu phi ln c lc thng k ph hp kh nng xc nh s kt hp nu c tn ti (xem Chng 3). C mu c th c tnh ty thuc vo cc yu t o lng ca thit k nghin cu: hin mc sai s chp nhn c pht hin s khc bit

C rt nhiu cng thc v phn mm my tnh tnh c mu sn c. Di y l hai cng thc tnh c mu n gin v hu ch: kim nh t hai mu kim nh so snh hai t l

Kim nh t hai mu
Cng thc tnh c mu cho kim nh t hai mu l: (vi = 0,05)

N = n1 + n 2 =

4 2 ( Z 0,975 + Z 1 ) 2 ( 1 2 ) 2

Cng thc ny yu cu chng ta phi ch ra bnh phng phng sai qun th - 2, vi phn b chun, gi tr Z0,975=1,96, Z1-, v d bng hiu s m chng ta cn pht hin. Gi tr Z1- l lc thng k k vng. Mc k vng ca lc thng k 1- = 0,80. V d vi chn mu tnh trng lng c th, bnh phng phng sai 2 = 64 kg l ph hp. Z0,975=1,96 v Z0,80 = 0,842, nh vy nu chng ta mun loi b gi thuyt khng (H0) l khng c s khc bit v trung bnh cn nng ca hai qun th khi hiu s ca hai trung bnh ln hn 4 kg, s ngi cn thit cho hai c mu l:

N = n1 + n 2 =

4 2 ( Z 0,975 + Z 1 ) 2 ( 1 2 ) 2

4(64)(1,96 + 0,842) 2 = 125,62 ( 4) 2

Thng thng phng sai qun th l khng c sn tham kho, tuy nhin, vn c th c c t mt s nghin cu khc trc y. Chng ta tnh ton cn thn gi tr N mt vi ln vi vic s dng phi hp cc gi tr 2, d, v cc lc thng k khc nhau. Mt iu quan trng cn lu l gi tr ca lc thng k, 1- > 0,80, khi mc tng ca lc mu nhng c mu s tng ln tng ng, nhng s tng ln ny l khng nhiu.

Kim nh so snh hai t l

kim nh so snh hai t l, vic tnh ton tng t nh trn, nhng cng thc c s dng l: (vi = 0,05)

N = n1 + n 2 =

4( Z 0,975 + Z 1 ) 2 [(

P1 + P2 P + P2 )(1 1 )] 2 2 ( P1 P2 ) 2

86 Chng 4 Lu rng cc t l qun th P1 v P2 phi c ch ra. Khi pht hin s khc bit ca P1 = 0,60 v P2 = 0,70, vi = 0,05, lc thng k 1- = 0,80, kt qu tnh ton l:

N = n1 + n 2 =

4(1,96 0,842) 2 [(

0,60 + 0,70 0,60 + 0,70 )] )(1 2 2 = 714,46 (0,10) 2

Vi cng thc ny, chng ta cng phi tnh ton cn thn gi tr N mt vi ln vi vic a vo cng thc nhiu mc lc thng k v cc gi tr P1 v P2 khc nhau.

Phn tch tng hp (Phn tch meta)

Phn tch tng hp c nh ngha l tng hp thng k ca cc s liu t cc nghin cu (c th so snh c) khc nhau, a ra tng hp nh lng chung ca ton b cc s liu c tp hp li xc nh xu th chung (xem Chng 5). V d v phn tch tng hp c trnh by trong hnh 5.8. Phn tch tng hp khc vi cc nghin cu dch t hc v y hc truyn thng ch n khng thu thp cc s liu mi. Thay vo , kt qu t cc nghin cu trc y c tp hp. Cc bc tin hnh mt phn tch meta nh sau: Hnh thnh vn v thit k nghin cu; Xc nh cc nghin cu ph hp; Loi b cc nghin cu khng c gi tr hoc nhng nghin cu c vn v phng php; o lng, tng hp v phin gii kt qu.

Yu t quyt nh ca nghin cu phn tch tng hp l tm kim cc nghin cu no, la chn v loi b chng ra sao. Mt bc quan trng na l o lng cc kt qu ca cc nghin cu trn mt thang o thng nht. iu ny cho php tin hnh so snh gia cc nghin cu thm ch khi cc nghin cu ny s dng cc o lng kt qu khc nhau. Phn tch tng hp l mt phng php khoa hc kh mi; nghin cu xc nh nhng k thut tt nht p dng vn ang trong qu trnh trin khai v m rng ra cc lnh vc mi. Phng php phn tch ny vn cha c chp nhn rng ri nh cc k thut thng k c truyn thng s dng lu di. Vic s dng phn tch tng hp trong y hc v dch t ang tng ln rt nhanh trong nhng nm gn y do cc l do v o c nghin cu, chi ph, v nhu cu c mt nhn nh tng hp v hiu qu ca cc can thip ring r cc nhm qun th khc nhau. iu ny c bit ng trong lnh vc th nghim lm sng, khi m c mu ca cc th nghim ring l thng qu nh cho php rt ra nhng kt lun t bt k mt th nghim no, mc d cc kt lun c th c rt ra t cc kt qu tng hp. V d, phn tch tng hp cho thy rng aspirin c tc ng c ngha n vic phng nga t qu th cp, thm ch khng mt nghin cu ring l no cho kt qu ny mt cch thuyt phc. Nhng ni dung ny s c cp chi tit trong nhng chng tip theo v tnh nguyn nhn.

Cc thng k sinh hc c bn: cc khi nim v cng c 87

Cc cu hi
4.1 4.2 4.3 4.4 4.5 4.6 4.7 Hy tnh trung bnh, trung, phng sai, lch chun, v sai s chun cho mu nghin cu ca 10 gi tr cn nng c a ra trong chng ny. Ti sao thu nhp bnh qun u ngi thng c a ra di dng trung v ca thu nhp m khng phi l trung bnh ca thu nhp? Nhng khc bit c bn gia hi quy tuyn tnh, hi quy logic, v cc m hnh hi qui cho phn tch s sng? Khong tin cy rng hay khong tin cy hp c gi tr hn trong phin gii s liu, ti sao? Nhng thng tin no cn c trong tiu ca bng trnh by s liu hoc kt qu? Phin gii nh th no ca h s b1 = 5,0 vi bin c lp x l gii, trong x1 = 1 l nam gii v x2 = 0 l n gii, khi kt qu ny thu c t m hnh hi qui a bin vi y = cn nng (theo kg) l bin ph thuc? Phin gii nh th no ca h s b1 = 0,5 vi bin c lp x l tui, vi x = tui (tnh theo nm), khi kt qu ny thu c t m hnh hi qui a bin vi y = cn nng (theo kg) l bin ph thuc?

88 Chng 4

Ti kiu tham kho

1. Hosmer DW, Lemeshow S. Applied Logistic Regression 2nd ed. John Wiley & Sons Inc., New York, 2000. 2. Hosmer DW, Lemeshow S. Applied Survival Analyses: Regression Modeling of Time to Event Data. John Wiley & Sons Inc., New York, 1999. 3. Petitti DB. Meta-Analysis, Decision Analysis and Cost-Effectiveness Analysis: Methods for Quantitative Synthesis in Medicine. New York, Oxford University Press, 1994. 4. Whitehead A. Meta-Analysis of Controlled Clinical Trials. Chichester, John Wiley & Sons Ltd., 2002. 5. Draper NR, Smith Hnh Applied Regression Analyses 3rd ed. New York, John Wiley & Sons Inc, 1998. 6. Gilbert EW. Pioneer maps of health and disease in England. Geog J 1958;124:172-183. 7. Tufte ER. The visual display of quantitative information. Cheshire, Graphics Press, 1983. 8. Gordon B, Mackay R, Rehfuess E. Inheriting the world: the atlas of children's health and the environment. Geneva,World Health Organization, 2004.

89

Chng 5

Tnh nguyn nhn trong dch t hc

Thng ip chnh
Nghin cu v nguyn nhn gy bnh v chn thng l c trng ca dch t. Him khi mt tnh trng sc khe do mt nguyn nhn gy ra. Cc yu t nguyn nhn c th c sp xp theo mt trnh t t nhng yu t gn nht ti nhng yu t xa hn nh kinh t vn ha x hi Cc tiu ch nh gi cc bng chng v nguyn nhn gm: mi lin quan theo thi gian, tnh hp l, tnh nht qun, mnh ca s kt hp, mi quan h liu-p ng, tnh thun nghch v thit k nghin cu.

Mt trng tm ca dch t hc l gp phn phng v kim sot bnh v ci thin sc kho. lm c iu ny, chng ta cn bit v cc nguyn nhn ca bnh hay chn thng v nhng bin php can thip nhm thay i nhng nguyn nhn ny. Chng ny m t cch tip cn dch t hc trong xc nh nguyn nhn gy bnh.

Khi nim v nguyn nhn

Hiu bit v nguyn nhn gy bnh hay chn thng khng ch quan trng trong vic phng bnh m cn gip ch cho qu trnh chn on v iu tr chnh xc. Khi nim v nguyn nhn l ch c tranh lun nhiu trong dch t hc. Qu trnh chng ta i n suy lun nhn qu - cc phn xt kt ni gia nhng nguyn nhn mc nh v tnh trng sc khe l ch chnh ca trit l khoa hc ni chung, v khi nim v nguyn nhn c nhng ngha khc nhau trong nhng bi cnh khc nhau.

Nguyn nhn hay cn

Mt nguyn nhn ca mt bnh hay chn thng l mt s kin, mt iu kin, mt c tnh hay s kt hp ca nhng yu t ny ng vai tr quan trng trong vic sn sinh ra mt tnh trng sc khe. V mt lgc, mt nguyn nhn phi xy ra trc mt tnh trng sc khe. Mt nguyn nhn c gi l nguyn nhn khi n chc chn sn sinh ra bnh hoc lm khi pht bnh v mt nguyn nhn c gi l cn khi thiu n th bnh khng pht trin. C mt s bnh hon ton do cc yu t di truyn ca c th gy ra v cc nguyn nhn khc ca bnh tng tc vi yu t di truyn lm cho mt s ngi d mc bnh hn mt s ngi khc. Thut ng cc nguyn nhn mi trng thng c s dng phn bit nhng nguyn nhn khng thuc di truyn vi cc nguyn nhn di truyn. Ngi ta ch ra rng gn nh lun lun c s kt hp ca cc nguyn nhn di truyn v cc nguyn nhn mi trng trong mi c ch nguyn nhn.1

90 Chng 5

a yu t
Mt nguyn nhn khng phi lun ch l mt yu t n l m thng bao gm mt s nguyn nhn cu phn (cn nguyn a yu t). Nhn chung, khng cn thit phi xc nh tt c cc cu phn ca mt nguyn nhn trc khi a ra bin php d phng c hiu qu, v vic loi b mt cu phn thng s gy tr ngi cho hot ng ca cc cu phn khc v v vy gip phng c bnh hay chn thng. V d, ht thuc l l mt cu phn ca nguyn nhn gy bnh ung th phi. Bn thn ht thuc l khng gy ung th phi, nhiu ngi ht thuc l ti 50 nm m khng mc ung th phi; cn c cc yu t khc, a phn cha c bit, mt ngi ht thuc l c th b ung th phi v cc yu t di truyn c th ng vai tr no . Tuy nhin, ngng ht thuc l s gim s ca ung th phi trong qun th mt cch ng k, k c khi cc nguyn nhn cu phn khc gp phn gy ung th phi khng thay i (Hnh 1.2).

Nguy c quy thuc phn trm (phn s quy thuc)

Nguy c quy thuc phn trm (xem trang 2) c th c s dng lng ha tc ng d phng ca vic loi b mt yu t nguyn nhn no . V d, bng 1.2 cho thy iu g c th xy ra nu nhng ngi cng nhn c phi nhim vi aming v ht thuc khng ht thuc v khng bao gi tip xc vi aming: khng bao gi ht thuc s gim t l t vong do ung th phi t 602/100.000 xung 58/100.000 (gim 90%) v khng bao gi phi nhim vi aming, nhng vn ht thuc s gim t l t 602 xung 123/100.000 (gim 80%). (Cu hi nghin cu 5.3 s khm ph su thm vn ny) Hnh 5.1. Nhng yu t cn nguyn ca bnh lao
Cc yu t di truyn Xm nhp vo m

Phi nhim vi vi khun

Thiu dinh dng

Vt ch cm nhim
Nh cht chi

Nhim bnh

Bnh lao

Ngho i

Yu t nguy c ca bnh lao

C ch bnh sinh ca bnh lao

v cn
Mi nguyn nhn c mt nguyn nhn cn ng vai tr l mt nguyn nhn cu phn. V d, trong mt nghin cu v mt v dch ng c thc phm, ngi ta c th thy mn salad g v kem trng ming l cc nguyn nhn gy a chy do Salmonella. Tuy nhin s hin din ca vi khun Salmonella l mt nguyn nhn cn ca bnh ny. Tng t, c cc nguyn nhn cu phn khc ca bnh lao, nhng

Tnh nguyn nhn trong dch t hc 91

nhim vi khun lao (Mycobacterium tuberculosis) l nguyn nhn cn (Hnh 5.1). Thng th bn thn mt yu t nguyn nhn khng phi l cn m cng khng phi l , v d ht thuc l mt yu t trong nguyn nhn gy bnh lin quan n mch mu no. Hnh 5.2. T sut t vong v tnh trng kinh t x hi Cng ha Hi gio Iran4

C ch gy bnh
Ngi ta, c bit l cc nh cn lm sng, ch trch cc nh dch t hc khng dng quan nim nguyn nhn vi ngha l iu kin duy nht gy bnh. Quan im v cn nguyn hn ch ny khng tnh n thc t l bnh thng c nhiu nguyn nhn. Cc chin lc d phng thng cn phi ng thi hng ti hn mt yu t nguy c. Ngoi ra, cc nguyn nhn c th c kt ni thnh mt con ng nguyn nhn trong mt yu t dn n mt yu t khc cho n khi cui cng tc nhn gy bnh hin din trong c quan b tn thng; iu ny cng c th c gi l h thng cp bc ca cc nguyn nhn. Cc nh cn lm sng c th, v d, gi nguyn nhn c bn ca bnh mch vnh lin quan n cc c ch t bo tng nhanh trong m thnh ng mch. Cc nghin cu nhm xc nh cc mi lin quan sinh bnh r rng l quan trng, nhng nhng khi nim cn nguyn cn phi c hiu trong bi cnh dch t rng hn. Thng th ngi ta c th t c nhng tin b ln trong phng bnh ch bng cch tc ng ti cc nguyn nhn xa. Ngi ta c th phng c cc trng hp mc t nhiu thp k trc khi xc nh c vi khun gy bnh cha ni n c ch hot ng ca n (Hnh 5.3). Tuy nhin, iu l th l ngay t nm 1854, Bc s John Snow ngh rng mt loi vi khun no l nguyn nhn gy bnh ny (xem Chng 9).

Nguyn nhn n l v a nguyn nhn

Da trn cng trnh nghin cu ca Pasteur v vi sinh vt, Henle v sau l Koch hnh thnh nn cc quy tc xc nh liu mt sinh vt c th no c gy nn mt bnh c th no khng. Nhng quy tc l: Sinh vt phi c mt trong mi ca bnh.

92 Chng 5 Sinh vt phi phn lp c v pht trin c khi cy trong mi trng thanh khit. Sinh vt , khi chng vo ng vt cm nhim phi gy nn bnh c th no . Sau phi thy sinh vt trn ng vt v phi xc nh c n.

Bnh Than (Anthrax) l bnh u tin p ng c cc quy tc ny v cc quy tc ny cng c chng minh l hu ch i vi mt s bnh truyn nhim v nhim c ha cht khc. Tuy nhin, vi nhiu bnh, c truyn nhim v khng truyn nhim, th cc quy tc ca Koch xc nh nguyn nhn bnh cha . Nhiu nguyn nhn tng tc ng thi vi nhau v mt nguyn nhn nh ht thuc l - c th l mt nguyn nhn ca nhiu bnh. Ngoi ra, yu t gy bnh (sinh vt gy bnh) c th bin mt khi bnh pht trin lm cho chng ta khng pht hin c yu t ny ngi bnh. Cc nh ca Koch hu ch nht khi mt nguyn nhn c hiu no l tc nhn gy bnh truyn nhim, nhim c ha cht hay yu t c th khc v khng c nhng ngi mang bnh nhng khe mnh: mt s kin tng i khng ph bin. Hnh 5.3. Cc nguyn nhn ca bnh t

Cc yu t ca nguyn nhn
C 4 loi yu t ng vai tr trong nguyn nhn gy bnh. Tt c c th l nhng yu t cn nhng him khi l gy mt bnh c th hoc mt tnh trng sc kho no . Cc yu t dn dt (predisposing factors), nh tui, gii, hay nhng yu t di truyn no c th lm cho h thng min dch hot ng km, chuyn ha ha cht c chm. Tnh trng sc khe trc km cng c th l nhng yu t to nn trng thi d cm nhim ca ch th i vi tc nhn gy bnh. Cc yu t thun li (hoc hn ch) (enabling or disabling factors), nh thu nhp, dinh dng, nh , chm sc y t khng hp l c th khuyn khch s pht trin ca bnh. Ngc li, nhng yu t tr gip s hi phc hoc duy tr sc kho cng c gi l cc yu t thun li. Cc yu t kinh t x hi quyt nh tnh trng sc khe cng quan trng nh nhng yu t thc y trong vic thit k cc chng trnh can thip.

Tnh nguyn nhn trong dch t hc 93

Cc yu t thc y (precipitating factors), nh phi nhim vi mt tc nhn gy bnh c th no c th lin quan vi vic khi pht mt bnh no . Cc yu t cng c (reinforcing factors), nh phi nhim lin tc, cc iu kin mi trng v lao ng nng nhc l nhng yu t lm trm trng thm bnh hoc chn thng. Thut ng yu t nguy c thng c s dng m t cc yu t c s kt hp dng tnh vi nguy c pht trin bnh nhng khng gy bnh. Khi nim ny c chng minh l c ch trong mt s chng trnh phng bnh. Mt s yu t nguy c (v d ht thuc l) c lin quan ti mt s bnh, v mt s bnh (v d bnh mch vnh tim) li c lin quan ti mt s yu t nguy c (Hnh 5.4). Hnh 5.4. Cc yu t nguy c ph bin ca cc bnh khng truyn nhim ch yu5

Cc nghin cu dch t hc c th o lng s ng gp tng i ca tng yu t vo vic pht sinh bnh v kh nng gim bnh tng ng t vic loi b tng yu t nguy c. Tuy nhin, khi nim a nguyn nhn c ngha l tng ca cc nguy c quy thuc phn trm cho mi yu t nguy c c th ln hn 100%.

Tng tc
Tc ng ca nhiu nguyn nhn ng thi thng ln hn tc ng m ngi ta d kin trn c s tng hp cc tc ng n l. Hin tng ny c gi l tng tc, v thng c minh ha bng v d nguy c mc ung th phi c bit cao nhng ngi va ht thuc va phi nhim vi bi aming (Bng 1.2). Nguy c ung th phi nhm ny cao hn nguy c c tnh trn c s cng nguy c nhng ngi ch ht thuc (10 ln) v nhng ngi ch phi nhim vi bi aming (5 ln); nguy c ny c nhn ln thnh 50 ln.

94 Chng 5

Trnh t/h thng cp bc ca cc nguyn nhn

a nguyn nhn v cc yu t nguy c thng c th c biu din di dng h thng cp bc ca cc nguyn nhn, mt s nguyn nhn c th l trc tip nht hoc gn nht (cc yu t thc y v c mt s nguyn nhn khc gin tip hoc xa hn (cc yu t thun li/hn ch). Ht phi khi thuc l nguyn nhn gn ca bnh ung th phi, trong khi tnh trng kinh t x hi thp li l nguyn nhn xa/gin tip c lin quan ti thi quen ht thuc, v gin tip ti ung thu vi. C rt nhiu khung l thuyt c pht trin hnh tng ha mi lin h gia cc nguyn nhn gn v xa v nhng tc ng sc khe cui cng. Mt trong nhng khung l thuyt nhiu tng ny l DPSEEA (D: driving forces: cc yu t thc y, P: pressure: sc p, S: state: tnh trng, E: exposure: phi nhim, E: effect: tc ng, A: action: hnh ng), c t chc y t th gii s dng phn tch cc yu t nguyn nhn, phng bnh v ch bo khc nhau trong mi lin h vi cc yu t mi trng c hi cho sc khe (Hnh 5.5). Mt khung khi nim tng t cng c pht trin cho d n Gnh nng bnh tt ton cu ca T chc Y t th gii.7 Khung khi nim a phi nhim, a tc ng nhn mnh vo mi quan h phc tp gia phi nhim vi yu t mi trng v tnh trng sc khe ca tr em. M hnh ny gi thit rng cc phi nhim mc c th c th dn n rt nhiu tnh trng sc khe khc nhau, v cc tnh trng sc khe c th quy cho nhiu phi nhim khc nhau.8 Trong cc nghin cu dch t kt ni mt hoc nhiu nguyn nhn vi mt tnh trng sc khe, iu quan trng l phi cn nhc mc m cc nguyn nhn khc nhau thuc cng cp bc hay cc cp bc khc nhau trong h thng cp bc nguyn nhn. Nu mt nguyn nhn ca mt nguyn nhn c a vo phn tch cng vi chnh bn thn nguyn nhn , th cn phi tnh n phng php phn tch thng k. Vic xc nh cp ca cc nguyn nhn v vic lng ha mi quan h gia chng s cung cp mt cch m t c ch ca nguyn nhn. V d, nhiu nc cng nghip tnh trng kinh t x hi thp c lin quan n tnh trng ht thuc, tnh trng ht thuc c lin quan n cao huyt p v cao huyt p th lm tng nguy c b t qu.

Hnh 5.5. Khung DPSEEA6

Tnh nguyn nhn trong dch t hc 95

Thit lp mi lin h nhn qu

Suy lun quan h nhn qu l thut ng c dng ch qu trnh xc nh xem liu s kt hp quan st c c kh nng l cn nguyn khng; gm c vic s dng cc hng dn v vic a ra nhng nhn nh. Qu trnh xc nh cn nguyn c th kh khn v gy tranh ci. Ngi ta lp lun rng vic suy lun nguyn nhn nn c gii hn o lng mt tc ng ch khng phi l qu trnh c hng dn theo tiu ch xc nh liu mt tc ng c hin din khng.1,9 Trc khi nh gi v s kt hp nhn qu ca mt mi quan h, nh nghin cu cn tm cc kh nng gii thch khc v s hin din ca s kt hp ny, v d nh yu t ngu nhin, sai s h thng v nhiu cn phi c loi b. Vic nh gi cc yu t ny c m t trong Chng 3. Cc bc nh gi bn cht ca mi quan h gia mt nguyn nhn tim tng vi mt hu qu c trnh by trong Hnh 5.6. Hnh 5.6. nh gi mi quan h gia mt nguyn nhn c th v kt qu

Tiu ch nh gi cn nguyn
Trung tm Ngoi khoa M s dng mt cch tip cn h thng xc nh bn cht ca mt s kt hp v i n kt lun rng ht thuc l gy ung th phi. Cch tip cn ny c Hill lm r hn.11 Trn c s ca nhng khi nim ny, mt tp hp nhng vn cn xem xt khi nh gi cn nguyn c lit k theo trnh t kim nh m cc nh dch t hc nn tun th khi i n kt lun v nguyn nhn ca bnh v c trnh by trong bng 5.1.

96 Chng 5

Mi quan h thi gian

Mi quan h v thi gian l iu kin ct li nguyn nhn phi c trc tc ng/kt qu. Tiu ch ny l tt yu, tuy nhin kh khn c th ny sinh trong nghin cu bnh-chng v nghin cu ct ngang khi vic o lng cc nguyn nhn tim tng v hu qu din ra trong cng mt thi gian. Trong trng hp nguyn nhn l yu t phi nhim c th o lng cc mc khc nhau, th iu kin thit yu l phi c phi nhim ln trc khi bnh pht trin tn ti mi quan h v thi gian chnh xc. Vic o lng phi nhim lp li nhiu thi im v nhng a im khc nhau c th cng c thm bng chng v mi quan h nhn qu. Bng 5.1: Cc hng dn tm nguyn nhn
Quan h thi gian Tnh hp l Tnh nht qun mnh Quan h liu-p ng Tnh thun nghch Thit k nghin cu nh gi bng chng Nguyn nhn c xy ra trc hu qu khng? (thit yu) S kt hp ny c nht qun vi nhng hiu bit c khng? (c ch tc ng, bng chng t thc nghim trn ng vt)? C thy kt qu tng t trong cc nghin cu khc khng? mnh ca s kt hp gia nguyn nhn v hu qu nh th no? (nguy c tng i) S gia tng phi nhim vi nguyn nhn tim tng c lm gia tng hu qu khng? Nu loi b phi nhim th c lm gim nguy c mc bnh khng? Bng chng c da trn thit k nghin cu tt khng? C bao nhiu loi bng chng dn ti kt lun?

Hnh 3.3 l v d v vn thi gian khi o lng phi nhim v hu qu. Hnh v minh cho thy nhit hng ngy cao (trn 30oC) Paris trong thi gian 2 tun ca thng 8 nm 2003 v vic tng t l t vong hng ngy cng trong thi gian ny. Mi quan h gia nhng ln sng nhit v t l t vong khu vc th tng cao c ghi nhn trc mt s thnh ph khc v c k vng xy ra vi tn sut gia tng do kt qu ca s thay i kh hu ton cu.

Tnh hp l
Mt s kt hp hp l c th l c quan h nhn qu khi n cng thng nht vi nhng hiu bit c khc. V d, cc thc nghim trong phng th nghim cho thy s phi nhim vi mt yu t nguy c c th no c th dn ti nhng thay i lin quan ti hu qu c o lng. Tuy nhin tnh hp l sinh hc l mt khi nim tng i v mt s s kt hp tng chng khng hp l c th cui cng li c quan h nhn qu. V d, quan im chim u th v nguyn nhn ca bnh t vo nhng nm 1830 c lin quan n m kh hn l s ly truyn bnh. Cho ti khi c cng trnh nghin cu ca Snow c xut bn th mi c bng chng ng h quan im v s ly nhim; rt lu sau ny Pasteur v cng s mi tm ra tc nhn gy bnh. S thiu ht tnh hp l c th n gin l s phn nh s thiu ht trong cc hiu bit khoa hc hin ti. Nhng s hoi nghi v hiu qu iu tr bng chm cu v php cha vi lng ng cn c th mt phn l do thiu thng tin v c ch sinh hc hp l. Mt v d gn y v tnh hp l l l do chnh i n kt lun v cn nguyn l bnh Creutzfeldt-Jacob (vCJD). Hp 5.1

Tnh nguyn nhn trong dch t hc 97

Hp 5.1. Bovine Spongiform Encephalopathy (BSE) v vCJD

Bnh Creutzfeldt-Jacob l mt dng bnh b in ngi hay l bnh BSE. c dch b in Anh vo nm 1987. 13 C hai bnh u dn n cht ngi v c nhng thay i v bnh l tng t trong no nhng ngi c bnh vCJD v nhng con b c bnh BSE. Nhng bnh ny l v d v cc bnh no xp truyn nhim gy ra bi tc nhn truyn nhim gi l mt prion. Dch gia sc gy ra bi thc n b nhim carcasses ca cc gia sc khc v bnh ny cui cng c kim sot bng cch cm s dng cc cht m ca ng vt nhai li lm thc n cho gia sc. Vo nm 1995 c ba trng hp mc bnh b in nhng ngi tr tui, v n nm 2002 tng s 139 trng hp bnh ngi c bo co. Mc d c nhng bng chng r rng v ly truyn qua ng ming, nhng nhiu chuyn gia kt lun rng dch ngi c lin quan n dch b v gy ra bi tc nhn truyn nhim tng t. Nhng bn khon v vic ly truyn ngi dn n nhng thay i trong chnh sch hin mu v vic s dng cc dng c phu thut dng mt ln ngy cng nhiu hn.

Nghin cu v nhng nh hng ti sc kho ca vic phi nhim vi ch mc thp l mt v d na v nhng kh khn ban u trong vic tm kim nhng bng chng dch t thuyt phc, k c khi cc th nghim ng vt cho thy tc ng ca ch n h thng thn kinh trung ng. Mt nghin cu dch t hc tr em cho kt qu tng t nh vy l c tnh hp l, nhng do cc yu t nhiu v cc kh khn trong o lng, nn cc nghin cu dch t hc u tin cho thy nhng kt qu mu thun. Tuy nhin, vic nh gi tt c cc s liu dch t hc sn c a ti kt lun tr em b nh hng mc phi nhim vi ch thp.14(Hp 5.2). Hp 5.2. Phi nhim vi ch tr em.
M vic theo di thng xuyn phi nhim vi nhim vi ch trn hng trm nghn mu mu ca tr em cho thy trong khi hm lng trung bnh ang gim v ch b cm trong cc nhin liu t, th rt nhiu tr em c c hm lng ch trong mu gia tng.15 Hm lng ch trong mu c cho l c th dn ti nguy c gy tn hi n no tr em c gim xung t 250 ug/l vo nm 1995 xung cn 100ug/l trong nhng nm gn y, v mt s nghin cu ch ra rng c 16 nguy c thm ch cn mc ch thp hn. iu hp l l vi cc cng c o lng chnh xc hn, ngi ta c th tm thy mt s tr em c th b nh hng cc mc thp hn. Phn ln cc nghin cu v vn sc khe mi trng ko di ny v ang c thc hin cc nc c thu nhp cao, nhng mc phi nhim vi ch v cc vn sc khe lin 17 quan ngy cng tng li ang c bo co cc nc c thu nhp trung bnh v thp.

Tnh nht qun

Tnh nht qun ngha l nhiu nghin cu cng cho mt kt qu ging nhau. iu ny c bit quan trng khi cc thit k nghin cu khc nhau c tin hnh trong cc bi cnh khc nhau, bi v kh nng tt c cc nghin cu u mc cng mt sai st s c gim thiu. Tuy nhin, thiu tnh nht qun khng loi tr s kt hp mang tnh nhn qu, bi v cc mc phi nhim khc nhau v cc iu kin khc nhau c th lm gim tc ng ca yu t nguyn nhn trong mt s nghin cu c th no . Hn na khi phin gii cc kt qu ca mt vi nghin cu, th nhng nghin cu s dng thit k tt nht s c cho trng s cao nht. Ngy nay c cc k thut tng hp cc kt qu ca nhiu nghin cu v mt vn , c bit l cc th nghim c i chng v c phn b ngu nhin. K thut ny gi l Phn tch tng hp (xem Chng 4), v c s dng kt hp kt qu ca mt s th nghim, mt trong s c th c c mu tng i nh, t a ra mt c lng chung tt hn v tc ng (Hnh 5.7).18

98 Chng 5 K thut tng hp c h thng s dng cc phng php c chun ha la chn v tng hp tt c cc nghin cu c lin quan ti mt ch c th vi mc ch loi b sai s trong tng hp v gii trnh mt cch c ph phn. K thut tng hp h thng, l mt phn ca Cochrane Collaboration, i khi nhng khng nht thit phi i cng vi phn tch tng hp.19 Hnh 5.7 minh ha kt qu ca 113 nghin cu bnh chng v 2 nghin cu thun tp v mi lin h gia h vm ming tr nh v vic ht thuc ph n trong thi k mang thai. Mt l do quan trng cho thy s khng nht qun hin nhin ca kt qu l do mt s nghin cu ban u c thc hin vi c mu nh. Nguy c tng i c lng c trong mi nghin cu c nh du bng mt hp; nhng ng ngang l khong tin cy 95%. Vi s liu tng hp t tt c cc th nghim, bao gm mt s lng ln cc s kin, khong tin cy 95% tng i hp. Nhn chung, vic ht thuc l trong thi k lm m c lin quan v lm tng 22% nguy c b h hm ch/vm ming: khong tin cy 95% cho thy nguy c ny tng t nht l 10% v cao nht l 35%.20 Phn tch tng hp (meta-analysis) cng c th c s dng tng hp kt qu t mt s loi nghin cu dch t hc khc chng hn nh cc nghin cu thi gian (time-series) v nhim khng kh hng ngy v t vong chung (Hp 5.3). Hp 5.3. nhim khng kh v t vong chung
Cc kt qu nghin cu t mt s lng ln nghin cu time-series cc thnh ph khc nhau ca M c tng hp li; mc d mt s nghin cu c nhng kt qu tri ngc, nhng ngi ta vn tm quan st thy s kt hp c ngha thng k gia phi nhim v t 21 vong. iu ny cng c thm l nhng ht vt cht trong khng khi ang lm tng t l t vong, mc d c ch chnh xc th vn cn cha r. Mt phn tch tng hp tng t v cc mc ozn v t l t vong cng gi mt mi quan h nhn qu, nhng vic phn tch b hn ch bi sai s xut bn22 c ngha l nhng nghin cu m khng c ngha thng k, hoc c ln mong i th khng c xut bn.

Hnh 5.7: Phn tch tng hp nguy c tng i b h vm ming con ca nhng b m ht thuc trong thi k mang thai so snh vi con ca nhng b m khng ht thuc 20

Tnh nguyn nhn trong dch t hc 99

mnh ca s kt hp
Mt s kt hp mnh gia nguyn nhn tim tng v hu qu c o bng ln ca t s nguy c (nguy c tng i), nhiu kh nng l s kt hp c cn nguyn hn l mt s kt hp yu, s kt hp yu ny c th b nh hng bi cc yu t nhiu hay sai s h thng. Cc nguy c tng i ln hn 2 c th c coi l mnh. V d nguy c nhi mu c tim cp ngi ht thuc l tng khong 2 ln so vi nhng ngi khng ht thuc. Nguy c ung th phi nhng ngi ht thuc so vi ngi khng ht thuc trong rt nhiu nghin cu tng t 4 n 20 ln. Tuy nhin trong dch t hc thng him thy nhng nghin cu cho kt qu v s kt hp cao nh vy. Trong thc t, mt s kt hp yu khng th loi tr c vic n l s kt hp c quan h nhn qu; mnh ca s kt hp ph thuc vo t l tng i ca cc nguyn nhn c th khc. V d, trong cc nghin cu dch t hc quan st ngi ta thy c mi lin quan yu gia ch n v nguy c mc bnh mch vnh v mc d mt s nghin cu thc nghim mt vi qun th nht nh c tin hnh nhng vn cha c kt qu chc chn c xut bn. Mc d thiu bng chng chc chn nhng ch n ni chung vn c coi l yu t cn nguyn ch yu dn n t l bnh mch vnh cao nhiu nc cng nghip.

Bng 5.2: T l phn trm ngi b khim thnh lin quan phi nhim vi ting n ni lm vic 24
Mc n trung bnh trong 9 gi (decibels) < 80 85 90 95 100 105 110 115 Thi gian phi nhim (nm) 5 0 1 4 7 12 18 26 36 10 0 3 10 17 29 42 55 71 40 0 10 21 29 41 54 62 64

Kh khn trong vic xc nh ch n l yu t nguy c ca bnh mch vnh l ch ch n cc qun th kh ging nhau v s bin i theo thi gian ca mt ngi th ln hn s bin i v ch n gia nhiu ngi. Nu mi ngi u c mt ch n t nhiu ging nhau th khng th nhn nh ch n l mt yu t nguy c. iu ny cho thy tm quan trng ca cc bng chng sinh thi. Tnh hnh ny c m t nh mt trong nhng c nhn b m v qun th m23, c ngha l rt nhiu nc c thu nhp cao, ton b cc qun th c nguy c vi mt yu t c hi.

100 Chng 5

Mi quan h liu - p ng
Hnh 5.8. S kt hp gia huyt p, mc tiu th rau qu v bnh tim25

Mi quan h liu - p ng xy ra khi thay i v mc ca nguyn nhn tim tng c lin quan ti nhng thay i v t l hin mc hay t l mi mc ca tc ng. Bng 5.2 minh ha mi quan h liu - p ng gia ting n v v vn gim kh nng nghe. Ting n cng tng v thi gian tip xc cng di th t l b khim thnh cng cao. Bng chng r rng v mi quan h liu - p ng trong nghin cu khng c sai s h thng cung cp nhng bng chng chc chn v mi quan h nhn qu gia phi nhim v bnh. Mi quan h liu p ng gia mc tiu th rau qu v nguy c mc bnh thiu mu c tim cc b tri ngc vi mi quan h liu p ng gia nguy c mc bnh v huyt p. Hnh 5.8 l mt v d cho thy iu kin kinh t x hi c th nh hng ti tnh trng sc khe. Cc iu tra c thc hin Anh cho thy mt mi quan h mnh gia mc thu nhp v vic tiu th rau qu. Hnh 5.9 cho thy mc tiu th rau qu tng lin tccng vi tng thu nhp. Hnh v cn cho thy nhng ngi thuc mc phn trm thu nhp thp hn s dng mt phn ln thu nhp ca h cho thc n. Chi ph cao hn cho ch n c t l rau qu cao hn c th l mt yu t quan trng trong m hnh tiu th ny. Nhng mi lin h ny gp phn cng c thm mi quan h liu p ng gia thu nhp v t vong: thu nhp cng thp, t vong cng cao.

Tnh nguyn nhn trong dch t hc 101

Hnh 5.9. Mc tiu th rau qu v tnh trng kinh t x hi26

400 30 T l thu nhp (%) 25 Mc tiu th (g) 300 20 200 15 10 100 5 0 1 2 3 4 5 6 7 8 9 10 Th p phn v theo mc thu nh p ca gia nh trn u ngi (1=th p nh t, 10=cao nh t) Mc tiu th (gam/ng i/ngy) Thu nhp chi cho thc phm 0

Tnh thun nghch

Nu vic loi b mt nguyn nhn tim tng no lm gim nguy c pht trin bnh th rt c kh nng l nguyn nhn gy bnh. V d, vic ngng ht thuc l lin quan ti gim nguy c ung th phi so vi nguy c nhng ngi tip tc ht thuc (xem Hnh 8.5). Pht hin ny cng c thm kh nng: ht thuc l gy ung th phi. Nu nguyn nhn dn ti nhng thay i nhanh chng khng th o ngc v sau gy bnh cho d c tip tc phi nhim na hay khng, th tnh thun nghch khng phi l iu kin cho vic xc nh cn nguyn.

Thit kt nghin cu
Kh nng mt thit k nghin cu chng minh c mi quan h nhn qu l iu quan trng cn phi xem xt. Bng 5.3 lit k cc loi nghin cu khc nhau v mnh tng ng khi nh gi cn nguyn. Cc thit k nghin cu ny c gii thiu trong Chng 3, vic s dng cc thit k ny cung cp bng chng cho mi quan h nhn qu c trnh by di y:

Nghin cu thc nghim

Cc th nghim lm sng c i chng v c phn b ngu nhin c thit k cht ch cho bng chng tt nht. Tuy nhin, him khi c sn bng chng t loi nghin cu ny v thng ch lin quan ti hiu qu ca iu tr v cc chin dch d phng. Cc th nghim khc nh th nghim cng ng, him khi c s dng tm hiu cn nguyn ca nghin cu. Thng thng, bng chng c c t nhng nghin cu quan st, hu ht bng chng v tc hi i vi sc kho ca ht thuc c c t cc nghin cu quan st.

Nghin cu thun tp
Cc nghin cu thun tp l cc nghin cu cho bng chng tt tip theo nghin cu thc nghim bi v nu c trin khai tt, cc sai s s c gim thiu. Mc d cc nghin cu bnh-chng c nhiu nguy c mc phi mt s loi sai s, nhng kt qu ca nhiu nghin cu bnh-chng ln c thit k tt cung cp nhng bng chng tt v bn cht nhn qu ca mt mi quan h; cc phn xt v mi quan h nhn qu thng phi c a ra khi thiu vng s liu t cc ngun khc.

102 Chng 5

Cc nghin cu ct ngang
Cc nghin cu ct ngang t c kh nng chng minh quan h nhn qu v chng khng cung cp bng chng trc tip v trt t thi gian ca cc s kin. Tuy nhin trt t thi gian thng c th c suy ra da vo cch m s liu phi nhim v tc ng c thu thp. V d, nu chng ta bit r rng tc ng sc khe l mi xy ra v vic phi nhim vi yu t nguy c tim tng c ghi chp trong mt b cu hi, trong cc cu hi v qu kh c th xc nh c r rng phi nhim xy ra trc khi tnh trng sc khe xy ra. Bng 5.3. Loi nghin cu v kh nng tng i chng minh nguyn nhn
Loi nghin cu Th nghim c i chng v phn b ngu nhin Nghin cu thun tp Nghin cu bnh-chng Nghin cu ct ngang Nghin cu sinh thi Kh nng chng minh mi quan h nhn qu Mnh Trung bnh Trung bnh Yu Yu

Cc nghin cu sinh thi

Cc nghin cu sinh thi cung cp loi bng chng yu nht nh gi quan h nhn qu, do tim n nguy c suy lun khng chnh xc ra c th t s liu khu vc hay quc gia. Tuy nghin Tuy nhin vi cc phi nhim m ngi ta khng th o lng mc c nhn theo cch thng thng c (chng hn, nhim khng kh, tn lu ho cht bo v thc vt trong thc phm, fluor trong nc ung), th bng chng t cc nghin cu sinh thi l rt quan trng. Khi cc mi quan h nhn qu c xc lp th cc thit k nghin cu sinh thi c thit k cht ch c th rt hu ch.27 Tuy nhin, trong mt s trng hp him khi cc thit k nghin cu sinh thi, c bit l nghin cu theo di dc, cho bng chng tt thit lp quan h nhn qu. Mt trong nhng v d ny c lin quan n dch t vong do hen. Vo nm 1968, vic bn thuc gin c trn ph qun khng c n thuc Anh v x Wales b cm v ngi ta thy s cht do hen tng ln trong thi gian t nm 1959 n nm 1966 trng vi s tng bn thuc gin c trn ph qun. Sau khi hn ch thuc gin c trn ph qun, t l t vong do hen gim xung. Kt qu tng t cng c quan st khi vic hn ch bn thuc gin c trn ph qun New Zealand vo nm 1989 c p dng.28

nh gi bng chng
ng tic l khng c tiu chun hon ton ng tin cy no xc nh liu s kt hp quan st c c mi quan h nhn qu hay khng. Vic suy lun cn nguyn thng mang tnh d bo/d kin v vic phn xt cn nguyn phi da trn c s cc bng chng sn c: lun lun tn ti s khng chc chn. Cc bng chng thng mu thun v khi i n kt lun thng phi c trng s thch hp cho cc loi nghin cu khc nhau. Khi xem xt cc kha cnh khc nhau ca mi quan h nhn qu ni trn, th vic thit lp c mi quan h thi gian ng l iu thit yu, mt khi mi quan h c thit lp, th trng s ln nht (trong vic nh gi nguyn nhn) c dnh cho tnh hp l, tnh nht qun v quan h liu-p ng. Kh nng mt s kt hp c mi quan h nhn qu cng cao khi nhiu loi chng c khc nhau dn ti cng mt kt lun.

Tnh nguyn nhn trong dch t hc 103

Cc chng c c c t cc nghin cu c thit k tt c bit quan trng, nht l khi cc nghin cu ny c trin khai nhng a im khc nhau. Thng tin v cn nguyn ca bnh v chn thng c s dng quan trng nht l trong lnh vc d phng, chng ti s tho lun trong cc chng tip theo. D con ng cn nguyn c thit lp trn c s s liu nh lng t cc nghin cu dch t hc, nhng cc quyt nh v phng bnh c th c nhiu tranh ci. Trong nhng tnh hung m mi quan h cn nguyn cha c thit lp tt nhng tc ng ca n c tm quan trng y t cng cng ln th nguyn l phng c th c p dng tin hnh bin php d phng nh mt bin php an ton; c gi l phng bnh phng nga (precautionary prevention)

Cu hi
5.1. 5.2. 5.3. Th no l suy lun cn nguyn? Cp ca cn nguyn c th c hiu nh th no? Lit k cc cu phn ca cc cp bc ny cho mt bnh c th S dng s liu Bng 1.2 tnh nguy c quy thuc phn trm ca vic ht thuc l v phi nhim vi aming cho bnh ung th phi. Nu cng cc nguy c ny li, th kt qu ln hn 100%. Gii thch v sao quyt nh cc cch tip cn phng bnh li quan trng, cn c thm nhng s liu g tnh nguy c quy thuc phn trm cho mi yu t nguy c ny. Lit k cc tiu chun thng dng nh gi bn cht nguyn nhn ca cc s kt hp quan st c. Mt mi lin quan c ngha thng k c chng minh trong mt nghin cu bnh-chng gia dng thuc cha hen v nguy c t vong do hen ngi tr tui. Bn cn c thm thng tin g trc khi c khuyn ngh hy b thuc ? Trong mt v bng pht bnh thn kinh nghim trng khng r nguyn nhn, cc gia nh ca bnh nhn ngh rng nguyn nhn l do mt loi du thc phm gi ca mt hng. Xem xt tiu chun nh gi nguyn nhn Bng 5.1, bn s c gng chng minh iu g trc tin? Loi nghin cu no s thch hp? Bn s can thip vo giai on no nu tng hp cc bng chng li cho thy du c th l nguyn nhn? V sao phn tch chui thi gian v nhng s kt hp ngn hn gia phi nhim vi yu t mi trng (chng hn nh thi tit nng) v t vong li c cho l mt phng php chp nhn c nh gi cn nguyn? Th no l phn tch tng hp v cn c nhng u kin g p dng phng php ny. Kt hp s liu trong Hnh 5.8 v Hnh 5.9, bn c th tnh c mi quan h liu p ng gia mc thu nhp v nguy c b bnh thiu mu cc b c tim v yu t trung gian l mc rau qu tiu th. Gi thit rng cc nhm phn trm cao hn v thp hn trong Hnh 5.8 cho mc rau qu tiu th tng ng vi hai mc phn trm cao v thp trong Hnh 5.9, nguy c tng i kt hp mc bnh thiu mu cc b c tim nhm phn trm cao nht so vi nhm thp nht v mc tiu th rau qu trong mt qun th s nh th no? xut bin ph y t cng cng c th lm gim nguy c cho nhm c thu nhp thp.

5.4. 5.5.

5.6.

5.7. 5.8. 5.9.

104 Chng 5

Ti liu tham kho

1. Rothman KJ, Greenland S. Causation and causal inference in epidemiology. Am J Public Health 2005;95:S144-50. 2. Marmot MG. The importance of psychosocial factors in the workplace to the development of disease. In: Marmot MG, Wilkinson RG, eds. Social determinants of health. New York, Oxford University Press, 1999. 3. Marmot M. Social determinants of health inequalities. Lancet 2005;365:1099104. 4. Hosseinpoor AR, Mohammad K, Majdzadeh R, Naghavi M, Abolhassani F, Sousa A, et al. Socioeconomic inequality in infant mortality in Iran and across its provinces. Bull World Health Organ 2005;83:837-44. 5. Armstrong T, Bonita R. Capacity building for an integrated noncommunicable disease risk factor surveillance system in developing countries. Ethn Dis 2003;13:S13-8. 6. Kjellstrom T, van Kerkhoff L, Bammer G, McMichael T. Comparative assessment of transport risks how it can contribute to health impact assessment of transport policies. Bull World Health Organ 2003;81:451-7. 7. Introduction and methods - Assessing the environmental burden of disease at national and local levels. Geneva, World Health Organization, 2003. (http:// www.who.int/quantifying_ehimpacts/publications/en/. 8. Briggs D. Making a difference: Indicators to improve children's environmental health. Geneva, World Health Organization, 2003. 9. Weed DL. Causal criteria and Popperian refutation. In: Rothman JK, ed. Causal Inference. Massachusetts, Epidemiology Resources Inc, 1988. 10. Smoking and health: report of the advisory committee to the Surgeon General of the Public Health Service (PHS Publication No. 1103). Washington, United States Public Health Service,1964. 11. Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965;58:295-300. 12. McMichael AJ, Campbell-Lendrum DH, Corvalan CF, Ebi KL, Githeko AK, Scheraga JD, et al. Climate change and human health, risks and responses. Geneva, World Health Organization, 2003. 13. Smith PG. The epidemics of bovine spongiform encephalopathy and variant Creutzfeldt-Jakob disease: current status and future prospects. Bull World Health Organ 2003;81:123-30. 14. Tong S, Baghurst P, McMichael A, Sawyer M, Mudge J. Low-level exposure to lead and childrens intelligence at ages eleven to thirteen years: the Port Pirie cohort study. BMJ 1996;312:1569-75. 15. Meyer PA, Pivetz T, Dignam TA, Homa DM, Schoonover J, Brody D. Surveillance for elevated blood lead levels among children in the United States, 1997 2000. MMWR 2003;52:1-21. 16. Canfield RL, Henderson CR, Cory-Slechta DA, Cox C, Jusko TA, & Lanphear BP. Intellectual impairment in children with blood lead concentrations below ug/l. N Engl J Med 2003;348:1517-26. 17. Wright NJ, Thacher TD, Pfitzner MA, Fischer PR, Pettifor JM. Causes of lead toxicity in a Nigerian city. Arch Dis Child 2005;90:262-6. 18. Sacks HS, Berrier J, Reitman D, Ancona-Berk VA, Chalmers TC. Metaanalysis of randomised controlled trials. N Engl J Med 1987;316:450-5. 19. Jadad AR, Cook DJ, Jones A, Klassen TP, Tugwell P, Moher M, et al. Method- ology and reports of systematic reviews and metaanalyses: a comparison of Cochrane reviews with articles published in paperbased journals. JAMA 1998;280:278-80.

Tnh nguyn nhn trong dch t hc 105

20. Little J, Cardy A, Munger RG. Tobacco smoking and oral clefts: a metaanalysis. Bull World Health Organ 2004;82:213-8. 21. Samet JM, Dominici F, Curriero FC, Coursac I, Zeger SL. Fine particle air pollu- tion and mortality in 20 US cities. N Engl J Med 2000;343:1742-9. 22. Bell ML, Dominici F, Samet JM. A meta-analysis of time-series studies of ozone and mortality with comparison to the national morbidity, mortality and air pollution study. Epidemiology 2005;16:436-45. 23. Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14:32-8. 24. Noise. (Environmental Health Criteria, No 12). Geneva, World Health Organization, 1980. 25. The World Health Report: Reducing risks, Promoting Healthy Life. Geneva, World Health Organization, 2002. 26. Robertson A, Tirado C, Lobstein T, Jermini M, Knai C, Jensen JH, et al., eds. Food and health in Europe: a new basis for action. WHO Regional Publications, European Series, No. 96. Copenhagen, World Health Organization, 2004. 27. Pearce NE. The ecologic fallacy strikes back. J Epidemiol Community Health 2000;54:326-7. 28. Pearce N, Hensley MJ. Beta agonists and asthma deaths. Epidemiol Rev 1998;20:173-86. 29. Grandjean P, Bailar J, Gee D, Needleman HL, Ozonoff DM, Richter E, et al. Implications of the precautionary principle in research and policy-making. Am J Ind Med 2004;45:382-5. doi:10.1002/ajim.1036

107

Chng 6 Dch t hc v phng nga cc bnh khng ly nhim

Thng ip chnh
Cc bnh khng ly nhim (mn tnh) hin ang l nhng th thch chnh ca y t cng cng hu ht cc nc. Cc nguyn nhn ca cc bnh mn tnh nhn chung c bit v cc can thip chi ph - hiu qu l sn c. Cch tip cn ton din i hi s phi hp c phng nga v kim sot cc bnh ny. Phng bnh ban u l kim sot v chin lc tt nht phng nga nhng v dch mi. Phng nga cp hai hng n cc c th nguy c cao v phng nga cp ba l nhm cch lm gim gnh nng bnh mn tnh.

Phm vi ca phng nga

S gim t l t vong trong sut th k mi chn cc quc gia thu nhp cao c bn l do gim t vong ca cc bnh truyn nhim. Hnh 6.1 trnh by t l t vong do bnh lao ti Anh v Wales trong giai on 18401968 v ch ra nhng thi im gii thiu cc o lng phng nga v iu tr c trng. Hu ht s gim t l t vong xy ra trc nhng can thip ny v c qui cho nhng ci thin v dinh dng, nh , v sinh v cc o lng sc kho mi trng khc.

Nhng khuynh hng hin ti ca t l t vong

Trong vi thp k qua, Xu hng gim t l t vong do bnh tim mch xy ra cc quc gia thu thp cao. T nhng nm 1970, cc t l t vong do bnh tim v t qu gim xung ti 70% ti c, Canada, Nht, Vng quc Anh v Hp chng quc M. Cc nc c thu nhp trung bnh cng c nhng ci thin v t l t vong do bnh tim mch v d nh Ba Lan. Nhng thnh tu ny l kt qu ca mt lot cc o lng phm vi rng c cc qun th v cc c th. Cc bin php phng nga tim nng cho cc bnh mn tnh l rt a dng (Hp 6.1). Vi t l t vong gim thm 2% mi nm, trong khong thi gian 10 nm c kh nng ngn nga t vong sm cho 35 triu ngi.2

108 Chng 6 Hnh 6.1. T l t vong chun ho theo tui do bnh lao Anh v Wale, 184019681

S ng gp tng ng ca cc bnh mn tnh v bnh truyn nhim vo t l t vong chung v ang thay i t th k trc. V d, Brazil cc bnh truyn nhim chim ti 45% t vong nm 1930, nhng ch cn chim 5% vo nm 2003 (Hnh 6.2). i lp li, t l t vong do bnh tim mch tng t 12% nm 1930 n 31% nm 2003.

Hnh 6.2. Nhng thay i v s ng gp ca bnh mn tnh v bnh truyn nhim vi t l t vong chung ca ngi dn th ph cc bang Brazil, 1930-20038

Tuy nhin, cc t l t vong thay i theo thi gian cn chu nh hng bi cc yu t khc, bn cnh s tng v gim ca cc v dch, v d nh do s thay i cu trc tui ca qun th.. Nhng thay i trong cc t l t vong cc quc gia thu nhp

Dch t hc v phng nga cc bnh khng ly nhim 109

cao c bit c ngha cc nhm tui tr nht, ni m cc bnh truyn nhim l nguyn nhn ca hu ht t vong. Cc chn thng giao thng hin nay ang l nguyn nhn hng u ca t vong tr em ti nhiu nc thu nhp cao.

Cc phng nga tim nng

S thay i m hnh bnh tt v t vong cho thy cc nguyn nhn chnh ca bnh l c th phng nga c. Nhng thm ch ngi kho nht cng s khng chng c ni khi n mt tui no , v nguy c t vong c i ca bt c qun th no l 100%. Tuy nhin, hu ht cc qun th b nh hng bi nhng bnh c th c th phng nga c. Cc nghin cu trn dn nhp c cho thy h thng mc cc loi bnh ca dn bn x. V d, t l ung th d dy ca nhng ngi Nht sinh ra Hawai thp hn nhng ngi sinh ra Nht bn. Sau hai th h sng M, nhng ngi Nht c t l cng t vong do ung th d dy nh nhng ngi dn M chung. S tht l phi mt mt th h hoc hn cc t l gim, iu ny gi tm quan trng ca mt phi nhim v d nh ch n t sm trong cuc sng.

Hp 6.1. Dch t hc bnh mn tnh: nn tng ca phng nga

Bnh mn tnh l nguyn nhn chnh ca t vong hu ht cc quc gia v chim n 36 triu t vong mi nm (xem Hnh 7.1). Chng chim ti 61% t vong ca ton th gii v 48% ca gnh nng bnh tt ton cu.3 20% t vong do cc bnh mn tnh xy ra cc quc gia thu nhp trung bnh ni m hu ht dn s th gii sng . Cc bnh khng truyn nhim hng u l: Cc bnh tim mch (CVD), c bit l bnh mch vnh v t qu (17,5 triu t vong) Ung th (7,5 triu t vong) Bnh ng h hp mn tnh (4 triu t vong); v i tho ng (1,1 triu t vong)

Cc c lng vng ch ra rng vi hu ht cc nc trn th gii tr Chu Phi, cc bnh mn tnh l cc nguyn nhn thng xuyn ca t vong hn cc bnh truyn nhim. Cc chn thng l nguyn nhn ca gn mt phn mi cc trng hp t vong - chim u th trong tt c cc vng, nguyn nhn ch yu l chn thng giao thng, chn thng ngh nghip v bo lc. Gnh nng chn thng ang gia tng hy ht cc quc gia thu nhp thp v trung bnh. Cc vn sc kho tm thn l nhng ng gp hng u cho gnh nng bnh tt ca nhiu quc gia v ng gp ng k vo s mi mc v mc trm trng ca nhiu bnh mn tnh, bao gm c cc bnh tim mch v ung th. Suy gim th lc v m lo, suy gim thnh lc v ic, cc bnh ming v cc ri lon v gen l nhng tnh trng bnh mn tnh khc m ng gp mt t l ng k trong gnh nng bnh tt ton cu. Nu khng c s quan tm ln hn cho cng tc phng nga, c tnh n nm 2030 bnh nhi mu c tim, t qu v i tho ng s chim ti bn trong mi t vong ca ngi 4 ln (35-64 tui) cc quc gia thu nhp thp v trung bnh. D on trong 10 nm ti t vong do bnh mn tnh s tng 17%. iu ny c ngha trong khong 64 triu ngi s t vong vo nm 2015, c 41 triu ngi t vong do mt bnh mn tnh. Tuy nhin, vic phng nga qui m ln l kh thi, do cc nguyn nhn ca cc bnh mn tnh c bit v tng 5-7 t nhau tt c cc vng v cc nhm nh qun th. Mt s lng nh cc yu t nguy c c th thay i c gii thch cho hu ht nhng ca bnh mi, v cc can thip da trn bng chng sn c, chi ph-hiu qu v c th p dng rng ri.9

110 Chng 6 S khc bit v a l trong s xut hin bnh trong mt quc gia v gia cc quc gia cng cung cp nhng bng chng quan trng cho cc bin php phng nga tim nng (Hnh 6.3). Ti vng quc Anh, t l t vong chun ho theo tui do ung th phi ca nam gim t 18/100.000 vo nm 1950 xung n 4/100.000 nm 2000. i lp li, sau cng khong thi gian ti Php, t l ung th phi gia tng. Ti Php, tnh trng ht thuc l tng xy ra ti mt vi thp k mun hn Anh, v t l ht thuc bt u gim ch t sau nm 1990. Tng t nh vy, c t l ung th phi ton cu ca ph n tip tc gia tng, nhng ti Anh, xu hng tng ny khng p dng.10

Hnh 6.3. Nhng thay i t l t vong do ung th phi la tui 35-44 Anh v Php, 1950-19999

Khung nguyn nhn

Dch t hc gip xc nh cc nguyn nhn c th thay i c ca bnh tt. Trong 50 nm cc nghin cu dch t v bnh mch vnh xc nh c nhiu t cc trng hp bnh, t cc yu t nguy c c nhn n cc c ch t bo trong thnh ng mch. Tuy nhin, nhng s khc bit ln gia cc qun th v cc mc yu t nguy c vn cha c hiu r. Suy lun cn nguyn cn tnh n c nguyn nhn gy bnh c th v cc vai tr ng gp ca x hi, kinh t, mi trng v chnh tr - ci gi l cc yu t ngc dng - nhng yu t vt qu s kim sot ca cc c th.

Cc yu t x hi quyt nh tnh trng sc kho

Cc yu t x hi quyt nh tnh trng sc kho l nhng iu kin trong con ngi sng v lm vic.14 cp n cc yu t x hi quyt nh tnh trng sc kho l cch cng bng nht ci thin sc kho cho tt c mi ngi. Chm sc y t tt l vn sng cn, nhng cc yu t c th lm hi n sc kho ngi dn v d nh v tr x hi, tnh trng nh v cc nguy c ngh nghip - cn phi c cp thc hin cng bng v sc kho.15,16 Cc iu kin x hi v mi trng khng tt c th dn n cc hnh vi khng mong i, m c th nh hng n cc mc ca cc yu t nguy c chnh ca cc bnh mn tnh quan trng (Hnh 6.4).

Dch t hc v phng nga cc bnh khng ly nhim 111

Hp 6.2. Tc ng ca gnh nng yu t nguy c ln nguy c c i

Cc nh dch t hc iu tra s c mt (hoc vng mt) ca cc yu t nguy c chnh ng 11,12 S vng mt ca cc gp nh th no n s gim t l t vong t cc bnh tim mch. yu t nguy c t tui 50 lin quan n nguy c c i rt thp ca bnh tim mch. V d, mt phn tch trn i tng nghin cu ca Framingham, nhng ngi khng mc bnh tim mch tui 50 cho thy s c mt ca 2 hoc nhiu hn 2 yu t nguy c chnh mang li nguy c c i pht trin bnh tim mch trn 69% nam v 50% n. So snh vi nhng ngi c tiu s nguy c ti u, ch c nguy c c i vi bnh tim mch l 5,5% nam gii v 8,2% n gii.13

Hnh 6.4. Cc yu t quyt nh sc kho v tc ng ca chng ln cc bnh mn tnh

Cc iu dng y t cng cng, cc nh y x hi hc, nh tm l hc, nh kinh t y t, cc nh nghin cu v lao ng, cc k s v sinh, cc chuyn gia kim sot nhim v v sinh lao ng tt c u lin quan n cc n lc phng bnh. Do s gii hn ca y hc iu tr tr nn r rng v cc chi ph chm sc y t ngy cng gia tng tt c cc quc gia, vn phng bnh ang ngy cng tr nn chim u th.

Cc cp phng bnh
C bn cp d phng, tng ng vi cc giai on pht trin bnh khc nhau, l phng bnh cp 0 (d phng cn nguyn), cp I, cp II v cp III. Bin php d phng nhm n cc yu t nguy c hoc cc iu kin c vai tr trong vic gy ra bnh. Trong mt s tnh hung, khi bng chng v vai tr gy bnh cha hon chnh, nhng nguy c ca vic khng ngn nga mt mi e do y t cng cng c cho rng l rt cao, cc hnh ng phng nga c th vn c thc hin v c gi l phng nga d phng. Cch tip cn ny thng thy trong lnh vc mi trng, ni m cc nguyn tc d phng c s dng trnh cc nguy c y t cng cng t cc qu trnh hoc cc sn phm.17 C s trng lp v kt hp trong cc cch tip cn d phng , nhng tt c cc cp u quan trng v b sung cho nhau. D phng cn nguyn v cp I ng gp hu ht cho sc kho ca c cng ng, trong khi d phng cp II v cp III thng tp trung vo nhng ngi c nhng du hiu ca bnh (Bng 6.1).

112 Chng 6

Bng 6.1. Cc cp d phng

Cp Cp 0 (cn nguyn) Giai on bnh Cc iu kin kinh t, x hi v mi trng dn n nguyn nhn Mc ch Thit lp v duy tr cc tnh trng lm gim thiu cc e do ti sc kho Hnh ng Cc o lng hn ch tnh cp bch ca cc iu kin mi trng, kinh t, x hi, v hnh vi Bo v sc kho bng cc n lc c nhn v cng ng, v d tng cng tnh trng dinh dng, cung cp tim chng, v loi b cc yu t nguy c mi trng Cc o lng sn c cho cc c th v cc cng ng pht hin sm, nhm kim sot bnh v gim thiu tn tt (v d thng qua cc chng trnh sng tuyn) Cc o lng nhm lm gim nh tc ng lu di ca bnh v tn tt; gim thiu s chu ng; ti a nhng nm sng tim tng c ch i tng ch Ton b qun th hoc cc nhm chn lc; thc hin thng qua chnh sch y t cng cng v tng cng sc kho. Ton b qun th, cc nhm chn lc v cc c th c nguy c cao; thc hin thng qua chng trnh y t cng cng.

Cp I

Cc yu t cn nguyn c hiu

Gim s mi mc ca bnh

Cp II

Giai on sm ca bnh

Gim t l hin mc ca bnh bng cch lm gim thi gian mc bnh

Cc c th mi c bnh; thc hin thng qua chn on v iu tr sm

Cp III

Giai on mun ca bnh (iu tr, phc hi chc nng)

Gim s lng v/hoc tc ng ca cc bin chng

Cc bnh nhn, thng qua phc hi chc nng

D phng cp 0 (d phng cn nguyn)

Cp d phng ny c xc nh l mt kt qu ca vic tng cng kin thc v dch t hc cc bnh tim mch. Bnh mch vnh c bit l xy ra trong mt phm vi ln ch khi cc nguyn nhn c bn c mt, v d ch n nhiu cht bo ng vt. Khi nguyn nhn ny vng mt trong phm vi ln- v d nh Trung Quc v Nhtbnh tim mch ch l mt nguyn nhn him ca t vong v bnh tt, mc d vi t l cao ca cc yu t nguy c quan trng khc nh ht thuc l v cao huyt p. Tuy nhin, ht thuc gy ung th phi ang gia tng v t qu do huyt p cao l ph bin Trung Quc v Nht. mt s nc thu nhp trung bnh, bnh tim mch ang tr

Dch t hc v phng nga cc bnh khng ly nhim 113

nn quan trng cc nhm thnh th thu nhp trung bnh v cao, nhng ngi nhim phi cc hnh vi nguy c cao. Cng vi s pht trin ca kinh t x hi, cc yu t nguy c ny c th c k vng s tr nn ph bin hn. Mc ch ca phng nga cp 0 l (Hp 6.3) trnh tnh cp bch v s thip lp ca cc li sng x hi, kinh t v vn ho m c bit l ng gp vo vic tng nguy c gy bnh. Hp 6.3. Ngn nga nhim khng kh
Ngn nga cp 0 cn thit chng li cc tc ng ton cu v nhim khng kh, v d nh hiu ng nh knh, ma axt, thng tng ozon v cc tc ng n sc kho ca khi. Vn cc ht trong kh quyn v s tp trung ca kh SO2 nhiu thnh ph ln vt qu lng ti a cho php theo T chc Y t Th gii v Chng trnh mi trng Lin Hip Quc (UNIEP). Cc thnh ph cc quc gia thu nhp thp v trung bnh sng da vo than nh mt ngun cung cp nng lng th c bit b nh hng. Cc chnh sch cng cng mc ch phng nga nhng mi e do ny l rt cn thit vi hu ht cc quc gia bo v sc kho (xem Chng 9). Phng nga cp 0 bao gm lp k hoch ca thnh ph tch bit cc vng cng nghip khi cc vng c dn sinh sng, to iu kin thun li cho giao thng cng cng hoc nng ng (i b, i xe p) v khuyn khch bo tn nng lng.

Hnh 6.5. Mi lin h ngc gia gi thc ca thuc l v tiu th thuc l, Nam Phi, 1961-20013

Tm quan trng ca d phng cp 0 thng c nhn ra khi qu mun. Tt c cc quc gia cn phi trnh s lan truyn cc li sng v s tiu dng khng lnh mnh cho sc kho. D phng cp 0 cc bnh mn tnh cn bao gm cc chnh sch quc gia v cch chng trnh v dinh dng. Nhng chng trnh nh vy cn lin quan n ngnh nng nghip, cng nghip thc phm v ngnh xut nhp khu. Cc quc gia cng cn cc chng trnh thc y hot ng th lc thng xuyn. V d v s dng thuc l cho thy s cam kt cao ca chnh ph l mt yu cu cho chng trnh phng nga cp 0 hiu qu. C mt bng chng tt l vic tiu th thuc l c th c gim bi thu v tng gi (Hnh 6.5). Bng chng dch t hc cho thy cc tc ng c hi ca thuc l cui cng dn n Cng c khung v Phng chng Tc hi Thuc l thng 2 nm 2006, hip c y t u tin c chp nhn bi cc quc gia thnh vin ca T chc Y t Th gii (xem Chng 10).

114 Chng 6

D phng cp I
Mc ch ca d phng cp I l gii hn s mi mc ca bnh bng cch kim sot cc yu t nguy c c trng ca bnh. Cc n lc d phng cp I c th nhm n: Ton b qun th vi mc ch lm gim nguy c trung bnh (chin lc qun th hoc s ng); hoc Nhng ngi c nguy c do kt qu ca nhng phi nhim c bit (chin lc c th nguy c cao).

Chin lc qun th
Cch tip cn qun th nhm chuyn s phn b ton qun th sang bn tri ca mt trc x tng tng, v d lm gim mc cholesterol trung bnh ca qun th (hoc huyt p). u im chnh ca chin lc qun th l khng phi xc nh nhm nguy c cao nhng mc ch n gin l lm gim- vi mt khi lng nh- mc mt yu t nhiu bit trong ton qun th. Thun li ch yu ca chng l mang li hiu qu nh cho nhiu c th bi v cc nguy c mc bnh tuyt i ca h l hon ton thp. V d, hu ht nhng ngi s dng dy an ton khi li t trong c i khng b lin quan n v m xe no, nhng li ch nh r rng c to ra t nhng c th khng bao gi lin quan n v m xe. Hin tng ny c gi l nghch l d phng.18 T l mi mc cao ca bnh tim mch hu ht cc quc gia cng nghip ho l do cc mc cao ca cc yu t nguy c trong ton qun th, khng phi vn ca mt thiu s. Mi lin h gia cholesterol huyt thanh v nguy c mc bnh mch vnh (Hnh 6.6) cho thy phn b cholesterol nghing mt t v bn phi. Hnh 6.6.
16 50

14

40

12

30

10

20

10

6 160 190 220 250 280 310 340

0 370 mg/dl

mmol/l

Dch t hc v phng nga cc bnh khng ly nhim 115

Ch c mt phn nh qun th c mc cholesterol huyt thanh trn 8mmol/l, v d nguy c rt cao ca bnh mch vnh. Hu ht cc t vong qui cho bnh mch vnh xy ra cc mc cholesterol trung bnh, mc ca hu ht qun th. Trong trng hp ny, phng nga cp I ph thuc vo nhng thay i c tc dng lm gim nguy c trung bnh trn ton qun th, v vy lm chuyn s phn b ton th xung mt mc thp hn. Hnh 6.7 so snh s phn b tng cholesterol trong ba qun th vi cc gi tr trung bnh khc nhau. C s chng cho gia nhng ngi nng cholesterol cao trong qun th A v qun th C. Nhng ngi c nng cholesterol cao trong qun th A s c xem xt c mc thp trong qun th C. Nhng s liu ny c ly t d n WHO MONICA (kim sot cc khuynh hng v cc yu t quyt nh ca bnh tim mch), bao gm cc iu tra qun th c thc hin t nht hai ln trong mt thp k trong 38 qun th xc nh v a l trong 21 quc gia.12,20 S liu cng chng minh nguyn tc rng mc d vic chn im ct no xc nh t l hin mc c th tu , nhng vic chuyn gi tr trung bnh ca qun th vi mt khi lng nh s c mt tc ng ln. Chuyn s phn b qun th t cc mc cao sang cc mc thp l mc ch ca phng nga cp I. Trong Hnh 6.7, ta c th quan st thy: Qun th A vi mc cholesterol trung bnh (4,0mmol/l) cng c mt t l hin mc cholesterol mu cao l thp (6%), thm ch nu im ct xc nh t l hin mc l > 5,0mmol/l. Qun th B vi mc cholesterol trung bnh 5,4mmol/l c th phn loi gn hai phn ba qun th (64%) c cholesterol cao nu im ct > 5,0mmol/l, nhng ch c 15% nu im ct l 6,2mmol/l. Vng di ng cong trong qun th C bao gm hu ht tt c mi ngi nu im ct thp > 5,0mmol/l.

Hnh 6.7. Phn b tng cholesterol (mmol/l) ti ba qun th: A (Thp), B (Trung bnh), C(cao).21

Chin lc c th nguy c cao

Cch tip cn khc l tp trung vo cc c th trn im ct t xc nh vi c gng lm gim cc mc cholesterol ca nhng c th ny. Mc d chin lc c th

116 Chng 6 nguy c cao (vi mc ch bo v nhng ngi d b nh hng) l hiu qu nht cho nhng ngi c nguy c cao nht mc mt bnh c th, nhng ngi ny c th ng gp t vo gnh nng bnh tt chung ca c qun th. Tuy nhin, nu nhng ngi c bnh c gp vo nhm nguy c cao ny, chin lc s ng gp nhiu hn cho vic lm gim chung gnh nng bnh tt (Hp 6.4). Nhc im chnh ca chin lc c th nguy c cao l thng i hi chng trnh sng tuyn xc nh nhm nguy c cao, thng l kh thc hin v tn km. Bng 6.2. lit k nhng u v nhc im ca hai chin lc ny. Hp 6.4. Chin lc nguy c cao: b thuc l
Cc chng trnh b thuc l cung cp mt v d in hnh v mt chin lc nguy c cao v rt ph hp do hu ht nhng ngi ht thuc u mong mun t b thi quen ny; v vy, nhng quan tm ca ngi ht thuc v cc bc s thng c khuyn khch mnh. Cc hiu qu ca can thip trc tip n cc c th nguy c cao thng c xu hng nhiu hn l cc tc ng c hi, v d nh cc tc ng ngn hn ca cai nghin nicotine. Nu chin lc nguy c cao thnh cng, n cng mang li li ch cho nhng ngi ht thuc bng vic lm gim tnh trng ht thuc th ng ca h. Cc chng trnh nh vy c xu hng hiu qu hn khi c hon chnh bng cc cch tip cn cng ng vi kim sot thuc l.

Trong nhiu trng hp, s phi hp chin lc qun th v chin lc nguy c cao l cn thit. Bng 6.3 so snh c hai phng php tip cn vi d phng i tho ng v bo ph. Chin lc nguy c cao cng ph bin hn khi tp trung vo nhng ngi c nguy c ton th cao hn l nhng ngi c nguy c cao ca mt yu t n c. V d, cc quyt nh v iu tr lm sng cho cc c th vi huyt p hoc cholesterol cao cn tnh n cc yu t khc nh tui, gii, ht thuc l v bnh i tho ng.

Bng 6.2. Cc u v nhc im ca cc chin lc d phng cp I

Chin lc i vi cng ng u im Ton din Tim nng ln cho ton b qun th Thch hp trn kha cnh hnh vi Thch hp cho c nhn Khuyn khch ch th Khuyn khch cc nh lm sng T s li ch-nguy c cao Chin lc i vi c nhn c nguy c cao

Nhc im Li ch thp i vi c nhn Thiu khuyn khch ch th Thiu khuyn khch cc nh lm sng T s li ch-nguy c thp Kh khn trong vic xc nh nhng c th c nguy c cao Hiu qu tm thi Hiu qu hn ch Khng thch hp trn kha cnh hnh vi

Dch t hc v phng nga cc bnh khng ly nhim 117

Bng 6.3. Cc cch tip cn vi d phng bnh i tho ng v bo ph

c trng M t Tip cn cng ng Cc chng trnh lm gim nguy c trn ton qun th vi khi lng nh (v d, s gim nh ch s khi c th trn mt cng ng). Tip cn nguy c cao Cc chng trnh lm gim nguy c ca nhng ngi c nguy c cao mc bnh bo ph (v d, gim cn nng ng k nhng ngi chun b bo ph v bo ph). Cc dch v d phng lm sng (sng tuyn, tm trng hp bnh v thc hnh lm sng da trn bng chng). Thay i li sng (t vn hnh vi, gio dc bnh nhn, pht trin cc k nng t chm sc). T l mi mc ca bnh gim nhng ngi c nguy c cao (gim t qu nhng ngi c iu tr cao huyt p, hoc gim i tho ng nhng ngi gim dung np glucose do thay i li sng tch cc) Chi ph cao cho mt ngi nhn vi s lng ngi tng i nh. Tc ng ln li sng c quan st thy trong vng mt n hai nm sau khi thc hin chng trnh gio dc tch cc, t vn, ng h v theo di. Cc kt qu u ra trung hn ca vic gim t l mi mc bnh c quan st thy bnh i tho ng.

Cc k thut

Thay i mi trng (lut php, chnh sch cng, gi c).

Thay i li sng (tip th x hi, ng h truyn thng i chng). Tc ng Cc kiu mu hnh vi c ci thin trn ton qun th, nguyn nhn mt phn bi s t la chn nh cc mi trng ng h (khch b hnh - ch nhng khu vc tng hot ng th lc ?

Chi ph

Chi ph nh cho mt ngi nhn ln vi qun th ln. Tc ng ln li sng c thy trong giai on ngn (gim tiu th cht bo sau khi cu to ca mt sn phm thc n c cu trc li; tiu th thuc l gim ngay lp tc sau khi cc o lng lut php hiu qu c thc thi).

Thi gian cho kt qu

D phng cp II
D phng cp II nhm lm gim bt cc hu qu trm trng ca bnh thng qua chn on v iu tr sm. Chin lc ny bao gm cc phng php o lng sn c cho cc c th v cc qun th pht hin sm v can thip hiu qu. D phng cp hai nhm vo giai on gia ca khi pht bnh v thi im chn on bnh thng thng, mc tiu l lm gim s hin mc ca bnh. D phng cp hai ch c th p dng i vi cc bnh trong lch s t nhin ca bnh c giai on sm m c th pht hin v iu tr d dng, v vy c th ngn chn bnh tin trin n giai on nghim trng hn. Hai yu cu chnh mt chng trnh d phng cp hai c ch l c phng php pht hin bnh an ton v chnh xc, tt nht l t giai on tin lm sng, v c cc phng php can thip hiu qu.

118 Chng 6 Hnh 6.8. Mi quan h gia gim t sut t vong do ung th c t cung gia nhng nm 1960-1962 v 1970-1972 v t l sng tuyn trn qun th mt s tnh thuc Canada23,24

Ung th c t cung l mt v d v tm quan trng ca d phng cp hai v n cng cng minh ho nhng kh khn gp phi trong nh gi gi tr ca cc chng trnh d phng. Hnh 6.8 cho thy s kt hp gia t l sng tuyn v gim t l t vong ung th c t cung trong cc tnh c chn ca Canada vo nhng nm 1970.23,24 u tin s liu ny cng b t cu hi v t l t vong ung th c t cung gim t trc thi im trin khai chng trnh sng tuyn. Cc nghin cu khc ng h gi tr ca nhng chng trnh sng tuyn nh vy, nhng chng trnh ny hin c p dng rng ri nhiu nc nhng khng phi tt c. Mt s quc gia thu nhp thp v trung bnh khng c c s h tng t chc cc chng trnh sng tuyn, v hu ht cc ph n trong cc quc gia thu nhp thp khng tip cn vi sng tuyn nh k.25 Vi s pht minh ra vacxin hiu qu cho virt u nh ngi, ung th c t cung c th tr thnh mt v d ca mt bnh m phng bnh cp I chim u th. Nhng v d khc v d phng cp hai c s dng ph bin l kim tra th lc v thnh lc ca tr em ang tui i hc, sng tuyn cao huyt p ngi trung nin; pht hin mt thnh lc cho cng nhn nh my, xt nghim da v chp phi pht hin bnh lao v hiu qu iu tr.

D phng cp ba
D phng cp ba nhm lm gim s tin trin hoc bin chng ca bnh v l kha cnh quan trng ca iu tr v phc hi chc nng. D phng cp ba l tp hp ca cc bin php nhm lm gim s suy yu, tn tt v gim thiu nhng tn tht do bnh tt gy nn v tng cng, khuyn khch s t iu chnh ca bnh nhn trong cc trng hp nan y. D phng cp ba thng gp kh khn khi tch bit vi iu tr, bi v mt trong nhng mc tiu trng tm ca vic iu tr cc bnh mn tnh l phng nga bnh ti pht.

Dch t hc v phng nga cc bnh khng ly nhim 119

Phc hi chc nng i vi bnh nhn b bi lit, t qu, chn thng, m la v nhiu bnh mn tnh khc l rt cn thit h c kh nng tham gia vo cuc sng hng ngy ca x hi. D phng cp ba gip ci thin tt tnh trng sc khe v thu nhp cho ngi bnh v gia nh. Mt kha cnh quan trng ca phng bnh cp III c bit vi nhng ngi tr tui b bnh hoc chn thng l phc hi kh nng lm vic v kim sng ca h. Nu cc h thng phc li x hi khng hot ng, thm ch mt giai on tm thi ca bnh tt c th gy nn nhng kh khn ln v kinh t cho cha m v gia nh ca ngi bnh. Cc nghin cu dch t hc cn cp n tnh trng kinh t ca nhng ngi bnh nh l mt trong cc yu t x hi quyt nh tnh trng sc kho.

Sng tuyn
Sng tuyn nhng ngi c bnh hoc yu t nguy c d bo bnh c khuyn khch bi cc li ch tim nng ca d phng cp II thng qua pht hin v iu tr sm.

nh ngha
Sng tuyn l qu trnh s dng cc xt nghim trn mt phm vi ln pht hin bnh nhng ngi c v b ngoi kho mnh. Sng tuyn thng khng phi l chn on m xc nh s c mt hay vng mt ca mt yu t nguy c, v v vy n yu cu s theo di v iu tr c th. Do i tng ca sng tuyn thng l nhng ngi cha c bnh, mt iu rt quan trng l cc xt nghim sng tuyn khng gy tc hi.26 Sng tuyn cng c th c s dng xc nh s phi nhim cao vi cc yu t nguy c. V d, cc mu mu ca tr em c th c sng tuyn lng ch cc vng s dng hm lng ch cao lm sn. Hp 6.5. Sng tuyn c mc ch
Khi tin hnh sng tuyn c mc ch nhng nhm phi nhim ngh nghip, th cc tiu chun t ra khng cn phi nghim ngt nh i vi sng tuyn chung cho qun th. Tc dng d phng c th hn ch (nh bun nn, au u), nhng sng tuyn c th c u tin nu hu qu bnh tt lm gim kh nng lao ng ca bnh nhn. Nhiu hu qu v sc kho ny sinh do phi nhim vi yu t mi trng c hi c xc nh v vic phng nga cc tc ng nh c th ng thi ngn chn cc hu qu nghim trng hn. Sng tuyn c mc ch l mt yu cu bt buc rng ri nhiu ni, v d trong cc hm m hoc i vi cng nhn tip xc ch hoc crom v c s dng trong theo di nhng trng hp mi mc nhim mi trng, v d nh ng c thu ngn (bnh Minamata) ti Nht vo nhng nm 1960 (xem Chng 1 v Chng 9).

Cc bin php sng tuyn

C cc loi C nhiu phng php sng tuyn, mi phng php c mt mc ch c trng ring: Sng tuyn s ng bao gm khm sng lc c mt qun th (hoc mt nhm). Sng tuyn a dng hay nhiu giai on bao gm s dng nhiu xt nghim sng tuyn khc nhau trong cng mt thi im. Sng tuyn c mc ch cho cc nhm i tng c phi nhim c bit, v d nh cng nhn cc xng c ch; thng c s dng trong sc kho mi trng v ngh nghip.

120 Chng 6 Sng tuyn tm ca bnh hay sng tuyn c hi hn ch i vi nhng bnh nhn m h i khm ti c s y t v mt vn sc kho no .

Cc tiu ch ca mt chng trnh sng tuyn

Bng 6.4 lit k nhng tiu ch chnh thit lp mt chng trnh sng tuyn.27 Nhng tiu ch ny lin quan n cc c tnh ca tnh trng bt thng hoc bnh, s iu tr v xt nghim sng tuyn. Quan trng hn ht, bnh cn c chng minh l s tr thnh trm trng nu khng c chn on sm; thiu ht chuyn ho bm sinh nh l phenylketonuria p ng tiu ch ny, cng nh mt s bnh ung th khc, nh ung th c t cung.

Bng 6.4. Cc yu cu xy dng mt chng trnh sng tuyn y hc

Bnh T l hin mc Lch s bnh La chn xt nghim Gi tr xt nghim Ti chnh Cc phng tin Tnh chp nhn c xc nh r bit Thi gian di gia cc du hiu u tin v bnh ton pht; ri lon trm trng v y hc m cn c mt bin php iu tr hiu qu n gin v an ton S phn b cc gi tr ca xt nghim trn cc c th b nh hng v khng b nh hng bit Chi ph hiu qu Sn c v d cung cp Cc qui trnh theo di mt kt qu dng tnh nhn chung c ng v chp nhn c vi c nhng ngi tin hnh sng tuyn v nhng ngi c sng tuyn. Cng bng trong tip cn vi cc dch v sng tuyn: hiu qu, chp nhn c v bin php iu tr an ton sn c.

Tnh cng bng

Thm vo , mt s vn khc cn cp trc khi thit lp mt chng trnh sng tuyn.

Cc chi ph
Cc chi ph ca mt chng trnh sng tuyn cn phi cn bng gia s lng cc ca bnh c pht hin v cc hu qu ca khng sng tuyn. Nhn chung, t l hin mc ca giai on tin lm sng ca bnh cn phi cao trong cng ng c sng tuyn, nhng i khi cn sng tuyn thm ch cho nhng bnh t l hin mc thp nhng li c nhng hu qu trm trng, v d nh bnh phenylketonuria. Nu tr em c chn on mc bnh ny khi sinh, chng cn c yu cu mt ch n c bit c th pht trin bnh thng. Nu tr khng c thc hin ch n ph hp, chng c th b chm pht trin tm thn v cn ch chm sc c bit sut c cuc i. Mc d bnh ri lon chuyn ho ny c t l mi mc thp (2-4 trn 100.000 tr sinh ra sng), chng trnh sng tuyn phng nga cp II c mc chi phhiu qu rt cao.

Thi gian dn
Bnh sng tuyn cn phi c thi gian dn di hp l; l khong thi gian gia khi bnh c th c chn on ln u bi sng tuyn v khi c chn on thng

Dch t hc v phng nga cc bnh khng ly nhim 121

thng trn cc bnh nhn biu hin cc triu chng. Mt thnh gic do ting n c mt khong thi gian dn kh di; ung th tu thng c thi gian dn ngn. Thi gian dn ngn ngha l bnh pht trin nhanh, v iu tr sm sau khi sng tuyn thng khng hiu qu hn khi bt u iu tr sau khi chn on thng thng.

Sai s chiu di
iu tr sm cn hiu qu hn lm gim t l t vong v bnh tt hn l bt u iu tr khi bnh chuyn sang giai on ton pht, v d iu tr ung th t cung. Mt phng php iu tr cn hiu qu v chp nhn c vi nhng ngi khng c triu chng bnh. Nu vic iu tr sm hn khng c hiu qu, chn on sm hn ch lm tng thi gian bnh nhn nhn thc c v bnh ca mnh; tc ng ny c gi l sai s chiu di hoc sai s thi gian.

Th nghim sng tuyn

Th nghim sng tuyn cn r tin, d thc hin, c cng ng chp nhn, ng tin cy v c gi tr. Xt nghim ng tin cy l loi xt nghim cho kt qu nht qun, n c gi tr nu phn loi chnh xc cc nhm ngi c bnh v khng c bnh, c o lng bng nhy v c hiu. nhy l t l nhng ngi thc s b bnh trong qun th sng tuyn c xc nh l c bnh bng cc xt nghim sng tuyn. (Khi c bnh, mc thng xuyn xt nghim sng tuyn pht hin c l bao nhiu?) c hiu l t l nhng ngi thc s khng b bnh c xc nh l khng c bnh bng cc xt nghim sng tuyn. (Khi khng c bnh, mc thng xuyn cc xt nghim sng tuyn cho kt qu m tnh l bao nhiu?)

Bng 6.5: Tnh gi tr ca mt xt nghim sng tuyn

Tnh trng bnh tt C bnh Xt nghim sng tuyn Dng tnh m tnh Tng cng a= dng tnh tht c = m tnh gi nhy c hiu Gi tr d on dng tnh Gi tr d on m tnh a c a+c Khng c bnh b d b+d b = dng tnh gi d = m tnh tht Tng cng a+b c+d a+b+c+d

= xc sut ca xt nghim dng tnh trong nhng ngi mc bnh. = a/(a + c) = xc sut ca xt nghim m tnh trong nhng ngi khng mc bnh= d/(b + d) = xc sut mt ngi c bnh khi xt nghim l dng tnh = a/(a + b) = xc sut mt ngi khng c bnh khi xt nghim l m tnh = d/(c + d)

Cc phng php tnh ton nhng o lng ny v cc gi tr d on dng tnh v d on m tnh c trnh by trong Bng 6.5.

122 Chng 6 Xt nghim l tng l c mt xt nghim sng tuyn vi nhy v c hiu cao, nhng chng ta cn phi cn bng gia nhng c tnh ny, bi v hu ht cc xt nghim u khng th c c hai. Chng ta quyt nh s cn bng ny bng mt im ct tu gia gii hn bnh thng v khng bnh thng. Nu ta mong mun lm tng nhy v bao hm tt c cc trng hp dng tnh tht, th s tng s cc trng hp dng tnh gi, tc l gim c hiu. Gim mc nghim ngt ca tiu chun i vi xt nghim dng tnh s lm tng nhy nhng gim c hiu. Ngc li, gia tng mc nghim ngt ca tiu chun dn n vic tng c hiu s lm gim nhy. Chng ta cng cn phi tnh m n gi tr d on dng tnh v m tnh khi din gii cc kt qu ca cc xt nghim sng tuyn. Quyt nh cc tiu chun thch hp i vi mt xt nghim sng tuyn ph thuc vo hu qu ca vic xc nh m tnh gi v dng tnh gi. pht hin nhng iu kin sc kho nguy him tr mi sinh th nhy cn tng ln v chp nhn chi ph tng ln ca s lng cc trng hp dng tnh gi cao (lm gim tnh c hiu). Sau cn phi theo di xc nh xem cc trng hp no l dng tnh tht v m tnh tht.

Lch s t nhin
Quan trng hn c, thit lp tiu ch ph hp i hi kin thc cn thit v lch s t nhin ca bnh quan tm v cc li ch v chi ph ca iu tr. Cn c cc phng tin y cho chn on, iu tr v theo di thng thng cc ca bnh mi chn on, iu m c th lm qu ti cc dch v y t. Cui cng, chng trnh v chnh sch sng tuyn cn phi c tt c nhng ngi lin quan chp nhn: cc nh qun l, cc chuyn gia y t v cng ng.

Tc ng
Gi tr ca mt chng trnh sng tuyn cui cng c xc nh bi hiu qu ca n ln t l bnh tt, t vong v tn tt. L tng l phi sn c cc thng tin v t l bnh tt trn nhng ngi c xc nh bnh thng qua sng tuyn v nhng ngi c xc nh bnh bng chn on da trn cc triu chng c bn. Do c xu hng tn ti nhng khc bit trn nhng ngi tham gia chng trnh sng tuyn v nhng ngi khng tham gia, bng chng tt nht ca hiu qu sng tuyn bt ngun t cc kt qu ca cc th nghim ngu nhin c i chng (Hp 6.6). Hp 6.6. Sng tuyn ung th v: mt nghin cu trng hp
Mt th nghim phn b ngu nhin c i chng trn 60.000 ph n c bo him tui t 40-64, nhng ngi c theo di trong vng 23 nm cho thy chp v c hiu qu lm gim t l t vong do ung th v (Bng 6.6). Mi nm sau khi tham gia vo nghin cu, t l t vong do ung th v nhm ph n c sng tuyn thp hn 29% so vi nhng ngi khng sng tuyn; sau 18 nm, t l ny thp hn 23%.

Bng 6.6. Cc t l t vong ung th v theo di theo thi gian28

S lng ph n ung th v Nhm sng tuyn Nhm chng % khc bit 307 310 S lng t vong (t khi bt u theo di) 5 nm 39 63 38,1 10 nm 95 133 28,6 18 nm 126 163 22,7

Dch t hc v phng nga cc bnh khng ly nhim 123

S gim tng i v t l t vong do ung th v mc 23-29% c v t n tng hn khi xem xt cc khi nim tuyt i (s gim t l t vong tuyt i l 0,05% trong s nhng ph n c sng tuyn). Mt th nghim ngu nhin c i chng khc ca Ban y t Quc gia Thu in cho thy li ch tng i ca mt ln tng t (31%), nhng cng ch ra rng kt qu ny i din cho mt li nhun thc l ngn nga c 4 trng hp t vong trn 10.000 ph n sng tuyn. Trong nhng nghin cu ny, s ci thin l v gim t l t vong ch i vi nhng ph n qu 50 tui. Mt li nhun ln hn v s nm cuc sng s t c nu sng tuyn ung th v ngn chn t vong do ung th v trn nhng ph n tr hn, nhng khng may l khng phi nh vy.29 Cui cng, chin lc phng nga tt nht khng nht thit bao gm sng tuyn.30 Khi mt yu t nguy c quan trng (v d nh ht thuc l, cao huyt p hoc khng hot ng th lc) c th c gim m khng cn la chn mt nhm nguy c cao cho hot ng phng nga, tt hn l tp trung vo cc ngun lc sn c v s dng chnh sch cng v cc o lng mi trng thit lp nhng tip cp i chng cho phng nga.

Cu hi
6.1 6.2 6.3 6.4 Hy m t 4 cp d phng. Cho cc v d mi cp ph hp nht vi cc cu phn mt chng trnh phng nga t qu ton din. Phng php no trong hai cch tip cn vi phng nga cp I bnh i tho ng v bo ph trong Bng 6.3 thch hp hn? Cc c tnh no ca mt bnh cho bit bnh ph hp vi sng tuyn? Cc thit k nghin cu dch t no c th c s dng nh gi mt chng trnh sng tuyn?

124 Chng 6

Ti liu tham kho

1. McKeown T. The role of medicine: dream, mirage or nemesis? London, Nuffield Provincial Hospitals Trust, 1976. 2. Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases: how many lives can we save? Lancet 2005;366:1578-82. Medline doi:10.1016/S0140-6736(05)67341-2 3. Preventing chronic diseases: a vital investment. Geneva, World Health Organization,2005. 4. Leeder SR, Raymond S, Greenburg H, Liu H. A Race against time. New York, Columbia University, 2004. 5. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367:1747-57. Medline doi:10.1016/S01406736(06)68770-9 6. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). A case control studyLancet 2004;364:93752. Medline doi:10.1016/S0140-6736(04)17018-9 7. The world health report: reducing risks, promoting healthy life. Geneva, World Health Organization, 2002. 8. Rouquairol MZ, Almeida Filho N, editors. Epidemiologia e Sade. Rio de Janeiro, Editora Meds, 1999. 9. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al (eds). Disease control priorities in developing countries, 2nd ed. New York, Oxford University Press, 2006. 10. Peto R, Lopez AD, Boreham J, Thun J. Mortality from smoking in developed countries, 2nd ed. Oxford, Oxford University Press, 2003. 11. Critchley J, Liu J, Zhao D, Wei W, Capewell S. Explaining the increase in coronary heart disease mortality in Beijing between 1984 and 1999. Circulation 12. Tunstall-Pedoe H, Vanuzzo D, Hobbs M, Mahonen M, Cepaitis Z, Kuulasmaa K, et al. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO 2004;110:1236-44. Medline doi:10.1161/01.CIR.0000140668.91896.AE 10.1016/S01406736(99)11181-4 13. Lloyd-Jones DM, Leip EP, Larson MG, DAgostino RB, Beiser A, Wilson PW. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 2006;113:791-8. Medline doi:10.1161/CIRCULATIONAHA. 105.548206 14. Marmot M. Social determinants of health inequalities. Lancet 2005;365:1099104. Medline 15. Lee JW. Public health is a social issue. Lancet 2005;365:1685-6. Medline doi: 10.1016/S0140-6736(05)66541-5 16. Bonita R, Irwin A, Beaglehole R. Promoting public health in the twenty-first century: the role of the World Health Organization. In: Kawachi I, Wamala S. eds. Globalization and health. Oxford, Oxford University Press, 2006. 17. Martuzzi M, Tickner JA. The precautionary principle: protecting public health, the environment and the future of our children. Copenhagen, World Health Organization Regional Office for Europe, 2004. 18. Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14:328.Medline

Dch t hc v phng nga cc bnh khng ly nhim 125

19. Prevention of coronary heart disease: report of a WHO Expert Committee. WHO Tech Rep Ser 1982;678. 20. Tolonen H, Dobson A, Kulathinal S, Sangita A, for the WHO MONICA Project. Assessing the quality of risk factor survey data: lessons from the WHO MONICA Project. Eur J Cardiovasc Prev Rehabil 2006;13:104-14. Medline doi:10.1097/00149831-200602000-00017 21. Tolonen Hnh Towards high quality of population health surveys. Standardization and quality control. Helsinki, National Public Health Institute, 2005. (http://www.ktl.fi/portal/4043) 22. Rose GA. The strategy of preventive medicine. Oxford, Oxford University Press,1992. 23. Boyes DA, Nichols TM, Millner AM, Worth AJ. Recent results from the British Columbia screening program for cervical cancer. Am J Obstet Gynecol 1977;128:692-3. Medline 24. Miller AB, Lindsay J, Hill GB. Mortality from cancer of the uterus in Canada and its relationship to screening for cancer of the cervix. Int J Cancer 1976;17:602-12. Medline 25. Katz IT, Wright AA. Preventing cervical cancer in the developing world. N Engl J Med 2006;354:1110. Medline doi:10.1056/NEJMp068031 26. Wald NJ. Guidance on medical screening. J Med Screen 2001;8:56. Medline doi:10.1136/jms.8.1.56 27. Cuckle HS, Wald NJ. Tests using single markers. In: Wald NI, Leck I, eds. Antenatal and neonatal screening. Oxford, Oxford University Press, 2000:20. 28. Shapiro S. Determining the efficacy of breast cancer screening. Cancer 1989;63:1873-80. Medline doi:10.1002/1097 0142(19890515)63:10<1873::AIDCNCR2820631002>3.0.CO;2-6 29. Wright C, Mueller C. Screening mammography and public health policy: the S0140-6736(95)92655-0 30. Strong K, Wald N, Miller A, Alwan A. Current concepts in screening for non10.1258/0969141053279086

127

Chng 7

Cc bnh truyn nhim: gim st dch t hc v phn hi

Thng ip chnh
Cc bnh truyn nhim mi xut hin v nhng bnh c ti xut hin trong bi cnh c nhng thay i v x hi v mi trng. Gnh nng bnh truyn nhim hin nay lm cho bnh truyn nhim tip tc l mi e da i vi sc khe cng ng tt c cc nc trn th gii. Cc phng php dch t hc to iu kin cho vic gim st, phng v kim sot cc v bng n dch bnh truyn nhim. Cc quy nh v sc khe quc t nhm mc ch thc y vic kim sot cc v dch mi.

Gii thiu
nh ngha
Bnh truyn nhim hay bnh ly l bnh pht sinh do s lan truyn ca mt tc nhn bnh c th ti c th cm nhim. Cc tc nhn truyn nhim c th truyn sang ngi trc tip, t ngi hay ng vt b nhim khc, hoc gin tip, thng qua vc t, cc vt th trong khng kh hay vt chuyn ch Vc t l nhng cn trng hay ng vt mang tc nhn truyn nhim t ngi ny sang ngi khc. Vt chuyn ch l nhng vt hay phn t trong mi trng b nhim (chng hn nh qun o, dao ko, nc, sa, thc n, mu, huyt thanh, dch rut hay cc dng c phu thut). Cc bnh ly truyn qua tip xc l nhng bnh c th c lan truyn t ngi ny sang ngi khc m khng c vc t hay vt chuyn ch trung gian. V d nh st rt l mt bnh truyn nhim nhng khng phi ly truyn qua tip xc, cn si v bnh giang mai l hai bnh truyn nhim qua tip xc. Mt s tc nhn gy bnh khng ch thng qua s nhim trng m cn thng qua c t ca cc hp cht ha hc to ra. V d Staphylococcus aureus l mt vi khun c th gy bnh trc tip cho con ngi, nhng ng c thc n c cha staphylococcal gy ra bi vic tiu ha thc n c nhim c t m vi khun sn sinh ra.

Vai tr ca dch t hc
Dch t hc pht trin t vic nghin cu cc v bng n dch bnh truyn nhim v s tng tc gia tc nhn, vt ch, vc t v cha. Kh nng m t nhng hon

128 Chng 7 cnh/tnh hung c xu hng lm bng pht dch trong qun th ngi chin tranh, di c, nn i v cc thm ha thin nhin lm tng kh nng kim sot s lan truyn bnh truyn nhim thng qua gim st, d phng, cch ly v iu tr.

Gnh nng bnh truyn nhim

c tnh gnh nng bnh truyn nhim ton cu ng u l HIV/AIDS, lao v st rt c trnh by trong hp 7.1. Cc bnh mi ni ln nh st xut huyt vi rt, bnh Creutzfeld-Jakob v Hi chng h hp cp nng (SARS), cng nh nhng bnh ti xut hin bao gm bch hu, st vng da, bnh than, dch hch, st dengue v cm lm tng gnh nng ln h thng chm sc sc khe, c bit nhng nc c thu nhp thp.2

Hnh 7.1. D bo nguyn nhn t vong hng u trn ton th gii, mi nhm tui, 2005: tng s t vong l 58 triu ngi.1
Cc bnh truy n nhim, , v tnh trng thiu dinh d ng 30% Cc bnh tim mch 30%

Chn th ng 9% Cc bnh mn tnh khc 9%

Ung th 13% Bnh tiu Cc bnh h ng hp mn tnh 7% 2%

Cc bnh truyn nhim: gim st dch t hc v phn hi

129

Hp 7.1. Gnh nng bnh truyn nhim trn ton cu

Cc bnh truyn nhim chim n 14,2 triu ci cht trong mt nm (Hnh 7.1). Khong 3,3 triu trng hp t vong khc c lin quan vi cc iu kin khi mang thai v lm m v thiu dinh dng. Tng hp li cc vn trn chim n 30% ca t vong trn ton th gii 1 v 39% gnh nng v khuyt tt trn ton cu Su nguyn nhn chu trch nhim cho gn mt na s trng hp cht non, ch yu l tr em v ngi tr tui v chu trch cho gn 80% trong tng s t vong do cc bnh truyn nhim l: Nhim khun ng h hp (3,76 triu) HIV/AIDS (2,8 triu) Cc bnh tiu chy (1,7 triu) Lao (1,6 triu) St rt (1 triu) Si (0,8 triu) Hu ht cc trng hp t vong xy ra cc nc c thu nhp thp. D bo ca T chc Y t Th gii cho thy rng, do cng tc phng bnh c thc hin tt hn nn tng s cht v nhng nguyn nhn ny s gim xung khong 3% trong vng 10 nm ti.

Nhng e da ti s an ton ca con ngi v h thng sc khe

Hnh 7.2. D bo cc nguyn nhn chnh ca gnh nng v tn tt iu chnh theo s nm sng (DALYs), cho mi nhm tui, 20051
Cc bnh tim mch 10% Cc bnh truy n nhim, , v tnh trng thiu dinh d ng 39%

Ung th 5% Cc bnh h hp mn tnh 4% Bnh tiu ng 1%

Chn th ng 13%

Cc bnh mn tnh khc, bao gm ri lon tm thn 28%

Cc bnh truyn nhim ang t ra mt mi e da khn cp ti sc khe c nhn v c kh nng e da s an ton ca nhiu ngi. Trong khi cc nc c thu nhp thp vn phi ng u vi nhng vn bnh truyn nhim, th ti cc nc c thu nhp cao, t vong do cc bnh mn tnh cng ang tng ln nhanh chng, c bit l cc th (xem Chng 6). Mc d cc nc c thu nhp cao c t l t vong do cc bnh truyn nhim thp hn mt cch ng k, nhng nhng nc ny vn phi chi ph cho mt t l ln ngi mc mt s bnh truyn nhim. V d cc nc c thu nhp cao th cc nhim khun ng h hp trn gy ra t vong ng k ch tr em v ngi gi. Tuy nhin s mc cc bnh tt c lin quan l ng k v nh hng ti mi nhm tui (Hnh 7.2).

130 Chng 7 S dng cc phng php dch t hc iu tra v kim sot bnh truyn nhim vn ang l mt thch thc cho nhng cn b y t. iu tra cn phi c tin hnh nhanh v thng vi ngun lc hn ch. Kt qu ca nhng iu tra thnh cng l rt hu ch, nhng tht bi trong vic thc hin iu tra mt cch hiu qu c th c hu qu nghim trng Trong i dch AIDS, 25 nm nghin cu dch t hc gip ch ra tc nhn, cc phng thc ly truyn v cc bin php d phng hiu qu. Tuy nhin, mc d c nhng kin thc nh vy, th th l hin nhim HIV c tnh trn ton cu vo nm 2006 l 38,6 triu trng hp, trong t vong mi nm l 3 triu ngi.

Dch v bnh lu hnh

Dch
Dch c nh ngha l khi cc trng hp mc bnh vt qu con s k vng ca mt cng ng hoc mt khu vc. Khi m t mt v dch, phi m t r v thi gian xut hin bnh, v a d v cc c tnh c th ca qun th ni xut hin bnh. Hnh 7.3: Bnh Kaposi sarcoma New York4
100

80

60

40

20

73

74

75

76

77

78

79

80

81

82

Nm

Vic nh gi s lng trng hp bnh th no l mt v dch thay i ty thuc vo tc nhn, kch thc v loi qun th phi nhim, v thi gian v a im xut hin bnh. Vic xc nh mt v dch cn ph thuc vo tn s thng thng ca bnh trong cng khu vc qun th xc nh trong cng mt ma ca nm. Ch mt s rt t trng hp bnh t trc n nay cha thy c trong mt khu vc, nhng c mi lin h vi nhau v thi gian v a im, cng kt lun v mt v dch. V d, mt bo co u tin v mt hi chng, sau ny c xc nh l AIDS, ch c 4 trng hp vim phi do Pneumocystis carinii nam thanh nin ng tnh.3Trc , bnh ny ch gp bnh nhn vi h thng min dch b tn thng. S pht trin nhanh chng ca v dch Kaposi sarcoma (cng l mt dng biu hin ca AIDS) New York c trnh by trong Hnh 7.3: 2 trng hp xy ra vo nm 1977 v 1978 v ti nm 1982 c 88 trng hp3.

Cc bnh truyn nhim: gim st dch t hc v phn hi

131

ng lc ca mt v dch c quyt nh bi cc c tnh nh tc nhn, phng thc ly truyn, v tnh mn cm ca vt ch con ngi. Ba nhm tc nhn gy bnh chnh tng tc vi nhau mt cch rt khc nhau cc bnh khc nhau. Mt s t vi khun, vi rt v k sinh trng gy ra hu ht cc v dch v vic hiu r c im sinh hc ca chng c th ci thin cc bin php d phng. Vc xin, bin php d phng cc bnh truyn nhim hiu qu nht cho n nay mi ch c pht trin cho mt s bnh do vi rt v vi khun gy ra. Nu nhng n lc nghin cu vc xin phng st rt thnh cng, th y s l vc xin u tin cho bnh v k sinh trng. Vc xin khng ch phng bnh tt trn c s c nhn, thng qua vic phng hoc lm gim bnh c nhn c phi nhim vi mm bnh, m cn trn c s qun th bng vic tc ng n min dch qun th (Hnh 7.4). Hnh 7.4. Min dch qun th. Nhng chm trn en cho thy nhng c nhn b nhim mt bnh truyn nhim do tip xc, nhng chm trn trng l nhng c nhn khng b nhim v chm trn xm l ngi c min dch. Cc mi tn ch hng ly truyn. Trong m hnh A, tt c mi ngi u mn cm, v tt c mi ngi b nhim bnh. Trong m hnh B, ch mt ngi c min dch, v nh vy 4 ngi c bo v, mc d 3 trong s h u mn cm.5

Trong mt v dch mt ngun, nhng ngi cm nhim phi nhim t nhiu ng thi vi mt ngun bnh. iu ny lm cho s lng ngi bnh tng rt nhanh ch trong vi gi. V dch t (bnh do vi khun) trnh by Chng 1 l mt v d v v dch mt ngun v v dch ny c kim sot hiu qu (bng cch loi b vic tip cn vi ngun bnh) 30 nm trc khi tc nhn thc s ca bnh c xc nh (Hnh 7.5). Trong cc v dch ly truyn do tip xc hay ly truyn rng ri (propagated), bnh c truyn t ngi ny sang ngi khc v s gia tng s trng hp bnh ban u xy ra chm hn. S lng ngi cm nhim v ngun nhim trng tim tng l nhng yu t then cht xc nh mc ly lan ca bnh. V d SARS ln u tin c cng nhn l mi e da ton cu vo thng 3 nm 2003. No lan truyn nhanh chng sang 26 nc, nh hng n c i tng nam v n trng thnh, trong mt phn nm trn tng s cc ca bnh xy ra nhng nhn vin y t (xem Chng 1).

132 Chng 7 Hnh 7.5: S bng n dch t ti London, thng 8 - thng 9 nm 18546

Cc bnh lu hnh/a phng

Cc bnh truyn nhim c gi l bnh lu hnh/a phng khi chng c phng thc xut hin kh n nh trong mt khu vc a l nht nh hay trong mt nhm qun th vi t l hin mc v mi mc tng i cao. Cc bnh lu hnh/a phng nh st rt vn ang l nhng vn sc khe ln cc nc nhit i c thu nhp thp. Nu cc iu kin v vt ch, tc nhn hay mi trng thay i th mt bnh lu hnh/a phng c th tr thnh dch. V d vic kim sot bnh u ma chu u b nh hng tiu cc sau chin tranh th gii ln th nht (Bng 7.1) Bng 7.1. T vong do bnh u ma mt s nc Chu u, 1900 - 1919
Nc Nga Italia c Phn Lan
a

Dn s/1918 (triu ngi) 134 65 34 3

1900-04 218000 165 18590 295

S t vong theo bo co 1905-09 1910-14 221000 200000 231 2149 155 136 8773 182

1915-19 535000a 1323 17453 605

Gm c nhng trng hp sng

Dch HIV l mt v d v bnh truyn nhim m tr bnh lu hnh nhiu khu vc, trong khi mt s khu vc khc HIV vn gy dch nhng qun th khng phi nhim trc .8 Trong trng hp bnh st rt v st dengue, mui chnh l vc t truyn bnh, cc khu vc c dch lu hnh b nh hng bi kh hu. Nu mt khu vc qu lnh hay qu kh v vc t khng th tn ti hay sinh sn, th bnh khng tr thnh bnh lu hnh. Vic m ln ton cu ang lm thay i kh hu mt s ni trn th gii theo hng lm tng ln ca cc khu vc c dch lu hnh, v cc bnh ly truyn qua vc t ang lan truyn sang nhng khu vc mi.9

Cc bnh truyn nhim: gim st dch t hc v phn hi

133

Cc bnh truyn nhim mi xut hin v ti xut hin

Trong nhng thp k cui ca th k 20, c hn 30 bnh truyn nhim trc y cha tng bit hoc nhng bnh c kim sot tt xut hin v ti xut hin vi nhng hu qu nghim trng.10 Trong nhng bnh , HIV/AIDS c tc ng ln nht. St xut huyt vi rt bao gm: Ebola, Marburg, Crimean-Congo, st vng da, West Nile v Dengue. Cc vi rt nghim trng khc bao gm: poliomyelitis (vi rt gy bi lit), Conronavirus SARS, v cm A. Mt dch nh bin th mi ca bnh Creutzfeldt-Jakob ngi xy ra tip theo mt v dch bnh b in gia sc (bonvine spongiform encephalopathy). Trong s cc bnh do vi khun gy ra, bnh than, bnh t, thng hn, dch hch, borelliosis, brucellosis (bnh gy ra cho tru b), Buruli ulcer l nhng bnh cho thy rt kh kim sot. V mt gnh nng bnh tt, st rt dn u cc bnh do k sinh trng gy ra, nhng cc bnh trng mi khoan (trypanosomiasis), leishmaniasis v dracunculiasis cng ang thch thc nhng n lc thanh ton chng. Nhng mi e da ti sc khe con ngi ny trong th k 21 i hi vic hp tc quc t trong vic gim st v phn hi hiu qu (Hp 7.2). Hp 7.2: Mng li cnh bo bng n dch v phn hi ton cu (GOARN)
Mng li cnh bo bng n dch v phn hi ton cu (GOARN) c pht trin t sau s kin bnh SARS ng ph vi nhng bnh c nguy c pht trin thnh dch v bnh mi xut hin. GOARN l mt mng li hp tc gia cc vin v cc mng li nhm tp trung ngun nhn lc v k thut xc nh, khng nh v phn hi nhanh vi nhng v dch c tm quan trng quc t. Mng li ny gp phn vo an ninh sc khe ton cu bng cch: chng li vic ly lan cc v dch quy m quc t m bo cc h tr k thut ph hp n c nhng ni b nh hng mt cch nhanh chng h tr vic sn sng ng ph vi dch lu di v nng cao nng lc.

Tt c cc nc c ngha v bo co nhng bnh c tm quan trng trong y t cng cng vi t chc Y t th gii theo nhng iu khon ca quy nh v sc khe quc t c iu chnh (Hp 7.3)

Trong khi mt s bnh mi xut hin ny c v thc s l mi, th mt s bnh khc nh st xut huyt vi rt c th tn ti trong nhiu th k nhng ch c cng nhn gn y do nhng thay i v sinh thi hay mi trng v ang lm tng nguy c nhim bnh ca con ngi, hoc kh nng pht hin nhng bnh ny c ci thin. y c gi l sai s xc nh (ascertainment bias) v rt kh lng ha. Nhng thay i v vt ch, tc nhn v iu kin mi trng c cho l phi chu trch nhim cho cc v dch nh dch bch hu, giang mai v lu vo u nhng nm 1990 nhng nc mi ginh c c lp ng u. i dch cm ny sinh khi mt vi rt cm mi xut hin, gy nhim trng cho con ngi v ly lan nhanh con ngi. Vi rt c quan tm gn y nht l chng cm A H5N1 (Hp 7.4), mt trong nhng loi vi rt thng gy cm cho gia cm v chim di c. Cc i dch cm nghim trng vo cc nm 1918, 1957 v 1968 gy t vong cho hn 10 triu ngi; V d c khong 40-50 triu ngi cht trong i dch cm nm 1918. Da trn nhng d bo t v i dch nm 1957, ngi ta c tnh rng c th c khong 1-4 triu ngi cht nu vi rt H5N1 bin i to ra dng cm ngi c th ly truyn d dng.13

134 Chng 7

Hp 7.3: Cc quy nh v sc khe quc t

Mc ch ca cc quy nh v sc khe quc t l ti a ha vic bo v chng li s ly lan quc t ca dch bnh, ng thi gim thiu nh hng n du lch v thng mi quc t.11,12 Quy nh v sc khe quc t p dng t nm 1969 kim sot bn bnh truyn nhim: t, dch hch, st vng da v u ma. Bn quy nh v sc khe quc t sa i vo nm 2005 c pht trin qun l tnh trng khn cp c tm quan trng quc t, khng cp n mt tc nhn c th no. Cc quy nh mi yu cu cc nc nh sau: thng bo vi TCYTTG tt c nhng tnh trng khn cp v y t cng cng c tm quan trng quc t xc nhn cc v dch theo yu cu ca TCYTTG duy tr ngun lc quc gia then cht cnh bo v phn hi sm vi dch hp tc c c nh gi nguy c v h tr quc t nhanh chng.

Dy chuyn ly bnh
Cc bnh truyn nhim pht sinh do tc ng qua li gia: tc nhn truyn nhim qu trnh ly truyn vt ch mi trng

Vic kim sot cc bnh truyn nhim c th i hi s thay i mt hoc nhiu thnh phn trn, ba thnh phn u tin u b nh hng bi mi trng. Cc bnh truyn nhim c th c nhiu dng biu hin khc nhau, thay i t nhim trng khng biu hin khng c du hiu hay triu chng lm sng n bnh nng v t vong. Nhim v ch yu ca dch t hc cc bnh truyn nhim l lm sng t qu trnh ly bnh xy dng, thc hin v nh gi cc bin php phng bnh thch hp. lm nh vy, nh nghin cu cn phi c kin thc v mi thnh phn trong dy truyn ly bnh trc khi tin hnh cc bin php can thip hiu qu. Tuy nhin, trong mt s trng hp,; chng ta c th kim sot c mt bnh ch vi hiu bit hn ch v mt dy chuyn ly bnh c th ca bnh . V d ci thin vic cung cp nc Lun n vo nhng nm 1850 ngn chn cc v dch t xy ra nhiu thp k trc khi ngi ta xc nh c tc nhn gy bnh t. Tuy nhin, ch c kin thc n thun th khng ngn chn cc v dch v ngy nay bnh t vn cn l mt nguyn nhn gy bnh v t vong quan trng nhiu ni trn th gii. Hp 7.4: Dch t hc v cm gia cm
Cc trang tri gia cm chu b nh hng nng n do loi virus gy bnh H5N1 vo nm 2003, v dch lan rng sang mt s vng thuc chu u v chu Phi vo nm 2005-2006, dn n vic phi tiu hy hn 40 triu gia cm nhm khng ch v kim sot dch. Virus khng hn d dng gy bnh ngi, hu ht 258 trng hp xc nhn nhim cm gia cm cho n thng 11 nm 2006 u c tin s tip xc lu di v trc tip vi gia cm nhim

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bnh.14 Tuy nhin, kh nng ly truyn thp cn phi c nhn nhn theo t l cht-mc rt cao: 50% s ngi nhim t vong. Thi gian bnh ngi l 2-8 ngy. Virus gy ra tnh trng st cao, sau l vim phi khng p ng vi khng sinh. V l thuyt, virus c th bin i sang dng c th d dng ly truyn sang ngi.15 Chin lc ch o nhm gii quyt kh nng i dch ngi l phi kim sot cc v dch gia cm cng nh ngi, v phng vic ly lan ca virus H5N1 sang nhng nc khc v gim c hi ly nhim 13-15 ngi.

Tc nhn gy bnh truyn nhim

Mt s lng ln vi sinh vt gy bnh ngi. Nhim trng l s xm nhp v pht trin hoc nhn ln ca mt tc nhn gy bnh truyn nhim vt ch. Nhim trng khng tng ng vi mc bnh v mt s trng hp nhim trng khng c biu hin v lm sng. Cc c tnh c th ca mi tc nhn gy bnh l yu t quan trng quyt nh bn cht ca vic nhim trng v c quyt nh bi cc yu t sau: Tnh cht gy bnh ca mt tc nhn l kh nng gy bnh ca tc nhn , c tnh bng t s gia s ngi mc bnh c biu hin lm sng vi s ngi c phi nhim. c tnh: mt o lng mc trm trng ca bnh, c th dao ng t rt thp n rt cao. Khi mt loi virut c gim c lc trong phng th nghim v c c tnh thp, th c th c dng gy min dch, v d nh virut bi lit. Liu nhim khun ca mt tc nhn gy bnh l lng cn thit gy nhim trng cc c th cm nhim. bnh ca mt tc nhn: l ni t nhin ca tc nhn gy bnh truyn nhim, c th l ngi, ng vt v mi trng. Ngun bnh l ngi hoc vt c cha tc nhn gy bnh. Cn c nhng hiu bit v c bnh v ngun bnh xy dng cc bin php kim sot hiu qu. Mt ngun bnh quan trng c th l ngi mang tc nhn gy bnh, ngi nhim bnh khng c biu hin lm sng. Thi gian mang tc nhn gy bnh thay i theo tng loi tc nhn. Ngi mang tc nhn gy bnh c th khng c triu chng bnh trong sut qu trnh hoc trong mt giai on nht nh ca qu trnh pht trin bnh. Nhng ngi mang tc nhn gy bnh c vai tr quan trng trong vic lm ly lan ra ton th gii virut suy gim min dch ngi do vic ly truyn qua ng tnh dc v tnh/khng ch tm trong st thi k di khng c du hiu lm sng.

Ly truyn
y l mt xch th hai trong dy truyn ly bnh, l s ly truyn hay ly lan ca mt tc nhn gy bnh qua mi trng hay ti mt ngi khc. Ly truyn c th trc tip hay gin tip (Bng 7.2).

Ly truyn trc tip

Ly truyn trc tip l s truyn trc tip tc nhn gy bnh t vt ch nhim bnh hay bnh n im xm nhp thch hp thng qua vic nhim trng ngi c th xy ra. y c th l tip xc trc tip nh ng chm, hn hay giao hp, hoc l s phn tn trc tip cc ht nh khi ho hay ht hi. Truyn mu v s nhim bnh qua nhau thai t m sang bo thai cng l ng ly truyn trc tip.

136 Chng 7

Ly truyn gin tip

Ly truyn gin tip c th qua vt chuyn ch, sinh vt trung gian hay qua khng kh. Ly truyn qua vt chuyn ch xy ra thng qua cc vt dng b nhim bn nh thc phm, qun o, khn tri ging v dng c nu bp. Ly truyn qua sinh vt trung gian xy ra khi tc nhn gy bnh c cn trng hay ng vt (vc t) truyn sang mt vt ch cm nhim; tc nhn gy bnh c th hoc khng sinh si ny n trong vt ch trung gian. Ly truyn qua khng kh vi khong cch xa xy ra khi c s pht tn cc ht rt nh n mt im xm nhp thch hp, thng l ng h hp. Cc ht bi cng thc y vic ly truyn qua khng kh, v d nh cc bo t nm c truyn theo cc ht bi. Bng 7.2: Cc phng thc ly truyn ca mt tc nhn gy bnh
Ly truyn trc tip ng chm Hn Giao hp Cc tip xc khc (sinh , th thut y t, tim thuc, cho b) Qua khng kh, khong cch gn (cc ht nh, ho, ht hi) Truyn mu Qua nhau thai Ly truyn gin tip Qua vt dng (thc phm, nc, khn mt, dng c nng nghip b nhim bn) Vt trung gian (cn trng, ng vt) Qua khng kh, khong cch xa (bi, ht nh) Ngoi ng tiu ha (tim bng bm tim b nhim bn)

Vic phn bit cc phng thc ly truyn bnh rt quan trng khi la chn nhng phng php kim sot bnh truyn nhim. C th ngn chn s ly bnh trc tip bng cch hn ch tip xc vi ngun bnh; s ly bnh gin tip i hi cc cch tip cn khc nhau nh cung cp mn chng mui, m bo thng gi, bo qun lnh thc phm s dng bm v kim tim v trng.

Vt ch
Vt ch l mt xch th 3 trong dy truyn ly bnh, v c nh ngha l ngi hay ng vt - ni tc nhn gy bnh xm nhp v pht trin thun li trong iu kin t nhin. ng xm nhp vo c th vt ch thay i ty thuc vo tc nhn gy bnh bao gm da, nim mc, ng h hp v tiu ha. Phn ng ca c th vt ch vi s nhim trng ht sc khc nhau v c quyt nh bng vic tng tc gia vt ch, tc nhn gy bnh v phng thc ly truyn. Ph ca s tng tc ny chy t khng c du hin hay triu chng r rng n bnh c biu hin lm sng trm trng, vi rt nhiu bin th gia hai thi cc ny. Thi k bnh l thi gian t khi tc nhn gy bnh xm nhp cho n khi c du hiu hoc triu chng lm sng u tin ca bnh xut hin, khong thi gian ny c th ch mt vi gi (nhim c thc n vi khun t cu) n nhiu nm (AIDS). Hu qu ca vic nhim khun phn ln c quyt nh bi kh nng khng ca vt ch. Kh nng khng ny thng c c thng qua phi nhim trc hoc min dch vi tc nhn gy bnh no . Min dch (hay tim chng) l vic bo v cc c th cm nhim khi mc bnh truyn nhim bng cch tim chng, c th theo nhng cch sau: tc nhn gy bnh truyn nhim sng nhng bin i (nh vc xin cho bnh si)

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cc sinh vt b bt hot (nh vc xin cho bnh ho g) gim c tnh (vc xin cho bnh un vn) polysaccharides vi khun.

Khng th - c hnh thnh nh l mt phn ca phn ng min dch t nhin vi mm bnh c th c tp hp t vic hin mu v c s dng nh mt cch phng bnh sau phi nhim mt vi bnh (nh bnh di, bch hu, thy u v vim gan B) cho nhng ngi cha c min dch y . Vic ny c gi l min dch th ng, v c tin hnh trn quy m nh hn nhiu so vi min dch ch ng do nhng nguy c, ch bo v chi ph ca n. Vic ly truyn th ng khng th ca m thng qua nhau thai cng c th truyn khng th ti bo thai.

Mi trng
Mi trng gi mt vai tr then cht trong vic pht trin bnh truyn nhim. V sinh chung, nhit , nhim khng kh, cht lng nc l nhng yu t nh hng n cc giai on ca dy truyn ly bnh (xem Chng 9). Ngoi ra, cc yu t kinh t, x hi nh mt dn s, s ng c v i ngho cng ng vai tr rt quan trng.

iu tra v kim sot cc v dch bnh truyn nhim

Mc ch ca iu tra mt dch bnh truyn nhim l xc nh nguyn nhn v bin php kim sot dch c hiu qu nht. Cng vic ny i hi phi c nhng hot ng nghin cu dch t mt cch c h thng v chi tit, cc bc cn tin hnh theo trt t hoc ng thi nh sau: iu tra s b ban u xc nh v thng bo cc trng hp bnh thu thp v phn tch s liu qun l v kim sot s liu thng bo cc pht hin v theo di.

iu tra
Giai on u tin ca iu tra l phi lm r chn on nhng trng hp nghi ng v khng nh l v dch thc s ang xy ra. iu tra s b ban u cng nhm a ra gi thuyt v ngun bnh, s ly lan ca bnh, ri sau ra nhng bin php kim sot kp thi. Nhng bo co sm v nguy c mt v dch c th da vo nhng quan st ca mt nh s cn b y t hoc cc bo co ny c th phn nh mt s con s tp hp c t h thng gim st cc bnh truyn nhim chnh thng hu ht cc nc. i khi, cn phi c mt vi bo co t cc c s y t cp qun; s lng ca bnh ch mt khu vc c th qu nh khng lm cho ngi ta cho l mt v dch.

Xc nh cc ca bnh
iu tra mt v dch nghi ng i hi phi xc nh c mt cch h thng cc trng hp mi mc v iu ny c ngha l nh nghin cu cn xc nh r cc tiu chun chn on mt ca bnh (xem Chng 2). Thng th chng ta cn thu thp thng tin chi tit trn t nht mt mu cc ca bnh. Cc ca bnh bo co sm trong mt v dch thng ch chim mt s nh trong tng s, cn phi m cn thn tt c cc trng hp bnh c th m t y v quy m ca v dch. Ngay sau khi

138 Chng 7 khng nh c dch, th u tin s mt l kim sot dch. nhng trng hp dch ly truyn qua tip xc nghim trng, thng cn thit phi theo di nhng ngi tip xc vi cc trng hp bnh c ghi nhn m bo xc nh c tt c cc trng hp bnh v gim thiu vic ly lan ca bnh.

Qun l v kim sot

Qun l mt v dch dch bao gm vic iu tr cc trng hp bnh, ngn chn s tip tc ly lan ca bnh v gim st hiu qu ca cc bin php kim sot dch. iu tr khng kh, tr cc v dch c quy m ln - c bit khi cc v dch pht sinh do s bin i ca x hi hay mi trng - cn cc ngun lc bn ngoi. Hot ng ca y t cng cng cn thit trong cc trng hp khn cp khi c cc v dch ca cc bnh khc nhau c m t chi tit.16 Cc bin php kim sot nhm vo vic kim sot cc ngun ly, hn ch s ly lan dch v bo v con ngi b phi nhim. Thng i hi phi c c 3 bin php ny. Tuy nhin trong mt s trng hp, c th ch cn loi b ngun bnh l , v d nh khng bn thc phm b nhim. Mt im quan trng trong cc bin php kim sot dch l thng bo cho nhn vin y t v cng chng v nhng nguyn nhn c th, nguy c mc bnh v cc bin php kim sot thit yu. iu ny c bit quan trng nu nh nhng ngi phi nhim cn phi c bo v bng cch gy min dch, v d nh trong khi ngn chn vic bng pht v dch si (Hp 7.5) Hp 7.5: Tim chng: cha kha phng v kim sot dch
Tim chng l mt cng c mnh qun l v kim sot cc bnh truyn nhim. Cc chng trnh tim chng c h thng c th rt hu hiu. v d, cho n cui nhng nm 1980, hu ht cc nc Nam M v M La tinh a vc xin s vo cc chng trnh tim chng quc gia v rt nhiu nc tin hnh cc chin dch tim chng tip theo tip cn vi tt c tr em v chn ng vic ly lan ca bnh si.

Khi cc bin php kim sot dch c thc hin th cn phi tip tc gim st m bo s chp nhn v tnh hiu qu ca cc bin php ny. Vic ny c th tng i n gin trong cc v dch cp tnh ngn ngy, nhng li kh i vi cc v dch di ngy. V d dch vim mng no do no m cu i hi nhng chng trnh tim chng c quy m ln. c bit cn trin khai cc nghin cu dch t dc v nghin cu trong phng th nghim nh gi c chi ph li ch lu di. Cc n lc trong qun l v kim sot dch HIV cho thy mt s tc ng. T khi pht hin nhng trng hp u tin, th cch tip cn then cht ca d phng cp mt l thc y/khuyn khch s dng bao cao su phng ly nhim HIV. Tng t nh vy, cc chng trnh pht bm kim tim cho nhng ngi tim chch ma ty c p dng hiu qu gim thiu vic ly lan ca HIV v virt vim gan B. Cc chng trnh gio dc tng cng nhn thc ca ngi dn v cch ly truyn HIV, v cch ngi dn c th lm ngn nga vic ly truyn HIV l mt phn thit yu ca d phng cp mt. Dch HIV c th ln ti nh im mt s nc Chu Phi v n . Nhng trng hp mi mc HIV r rng cao nht Kenya khong vo u cho n gia nhng nm 1990.18 Do thi k tim tng t khi nhim HIV cho n lc cht, nn t l hin mc vn tip tc gia tng trong khi t l mi mc gim, nh im vo nm 1997 khi t l t vong tng vt bng vi t l mi mc. T l hin mc HIV (t l ca nhng trng hp hin ang nhim HIV) cng bt u gim Nam n . Xu th tri

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ngc nhau ny c th gii thch do nhng n lc can thip nhm vo vic gim s lng cc i tc tnh dc ng thi v tng vic s dng hiu qu bao cao su.

Gim st v thng bo nh ngha

Gim st sc khe l vic thu thp, phn tch v phin gii cc s liu v sc khe cn thit cho vic lp k hoch, thc hin v nh gi cc hot ng y t cng cng mt cch h thng lin tc. Gim st cn phi gn vi vic cng b kt qu mt cch ng lc, nhm thc hin cc bin php phng bnh mt cch hiu qu. Cc c ch gim st bao gm thng bo bt buc v bnh, cc h thng ghi nhn bnh (c th l trn quy m qun th, hoc quy m bnh vin), cc iu tra lin tc hoc lp li v tng hp s liu cho thy xu th v phng thc tiu th v hot ng kinh t.

Quy m ca gim st
Quy m gim st rng, t cc h thng cnh bo sm thng bo nhanh trong trng hp cc bnh truyn nhim cho n thng bo mt cch c k hoach trogn trng hp cc bnh mn tnh m nhn chung c thi gian bnh (lag time) di gia phi nhim v bnh. Hu ht cc nc c nhng quy nh bt buc bo co vi mt s bnh. Danh sch nhng bnh phi thng bo ny thng gm nhng bnh c th phng c bng tim vc xin nh bi lit, si, un vn, bch hu cng nh mt s bnh truyn nhim khc lao, vim gan, vim no v phong. Vic bo co cng l bt buc vi mt s bnh khng truyn nhim nh t vong m, chn thng cc bnh ngh nghip v mi trng nh nhim c thuc tr su. Bo co bt buc trong mt s iu kin c th l mt phn ca gim st. Gim st cn mt s ng dng khc (Hp 7.6). Hp 7.6. Cc ng dng ca gim st
Gim st l mt phn thit yu trong thc hnh dch t v c th c s dng : Cng nhn nhng trng hp bnh bit lp hoc co cm nh gi tc ng y t cng cng ca cc s kin v nh gi xu th o lng nhng yu t cn nguyn ca bnh Theo di tnh hiu lc v nh gi tc ng ca cc bin phop phng v kim sot, cc chin lc d phng v nhng thay i trong chnh sch y t Lp k hoch v cung cp dch v chm sc sc khe Ngoi vic c lng lng quy m ca mt v dch, theo di xu th ca n, cc s liu c th c s dng : cng c cam kt vn ng cng ng vn ng cc ngun lc.19

Cc nguyn l gim st
Mt nguyn l then cht ca gim st l ch bao gm nhng iu kin m gim st c th dn n phng bnh mt cch hiu qu. Mt nguyn l quan trng na l h thng gim st nn phn nh gnh nng bnh tt ni chung ca cng ng. Cc tiu ch khc la chn bnh bao gm: t l mi mc v hin mc cc ch bo v mc trm trng (t s cht mc)

140 Chng 7 t l t vong v t l t vong sm mt ch s v mt nng sut lao ng (s ngy nm vin) cc chi ph y t kh nng d phng tim nng dch cc khong trng thng tin v nhng bnh mi

Cc ngun s liu
Cc ngun s liu c th cho chung cc bnh hoc lin quan n bnh c th v bao gm nhng ngun sau: bo co v t vong v bnh tt h s bnh n chn on ti phng xt nghim bo co v v dch s dng vc xin h s ngh m nhng thay i v mt sinh hc ca tc nhn, vc t hay cha ngn hng mu Gim st c th thu thp s liu v bt c thnh phn no trong chui nguyn nhn bnh cc yu t nguy c v hnh vi, cc bin php phng bnh, cc trng hp bnh v chi ph chng trnh hay iu tr. Phm vi ca h thng gim st thng b gii hn bi ngun nhn lc v ti chnh.

Gim st trn thc t

Gim st phi da vo h thng bo co thng quy cc trng hp nghi ng trong phm vi h thng sc khe, sau l xc nhn v khng nh. Vic thng bo ch ng v ph hp gm t cc bin php ngn chn a phng n iu tra v ngn chn c thc hin bi mt i ng chuyn gia cao cp. Gim st i hi theo di cn thn lin tc tt c mi kha cnh ca vic xut hin v ly truyn bnh, cc bin php thng s dng c phn bit bi tnh kh thi, ng u v s mau l ca chng hn l tnh xc thc han ton. Vic phn tch s liu t mt h thng gim st cho bit liu c s tng ln ng k s trng hp bnh bo co khng. rt nhiu nc, khng may l h thng gim st khng y , c bit nu cc h thng ny ph thuc vo vic thng bo t nguyn. Rt nhiu mng li, gm c cc t chc phi chnh ph, cc nhm tho lun qua internet, cc cng c tm kim trn mng ton cu v cc mng li v phng th nghim v o to cung cp nhiu cch hu hiu tm kim thng tin cho php thng bo quc t mt cch c t chc. H thng thng tin y t (sentinel) m mt s t bc s bo co theo mt danh sch xc nh cc ch c la chn cn thn cc ch ny c th thay i theo thi gian ngy cng c s dng nhiu cung cp thm thng tin cho vic gim st cc bnh truyn nhim v mn tnh. Gim st cc yu t nguy c ca bnh mn tnh c trnh by trong Chng 2. Mt mng li (sentinel) theo di cht ch mt mu ca qun th nhm cung cp cc bo co theo mu chun v u n v nhng bnh c th no v cc quy trnh trong chm sc sc khe ban u. Cc thng tin phn hi c cung cp u n v nhng ngi tham gia c mi lin h lu di vi cc nghin cu vin.

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Phn tch v phin gii s liu gim st

Gim st khng ch n thun l thu thp s liu, v vic phn tch, cng b v s dng kt qu d phng v kim sot cng quan trng khng km. Nhiu chng trnh y t cng cng c nhiu s liu hn rt nhiu so vi kh nng phn tch ca h (Hp 7.7) Hp 7.7. Lao v s dng s liu gim st
Lao l mt bnh truyn nhim ti xut hin quan trng, v cc chng trnh lao c s liu rt phong ph. H thng gim st lao thng l tng i tt (so vi cc vn sc khe khc) bi v lao l mt bnh e da s sng ca hu ht ngi trng thnh, h bit tm n cc bc s thm khm, cc bc s ny c lu gi h s bnh n. Hn na vic iu tr lao thng c gim st, v vy c rt nhiu thng tin v kt qu iu tr. Mt s trong s nhng thgn tin ny vn dng s liu th; mt s s liu quan trng khc c tp hp ln cp trung ng. rt nhiu nc, h thng gim st cn c c thng tin t cc cuc iu tra quy m qun th, v hai loi s liu c th c s dng b sung cho nhau. Vic phn tch s liu gim st thng quy c th quyt nh nhng vic nh sau: gnh nng v lao quy m quc gia xu hng v t l mi mc hin hnh tnh nht qun trong t l pht hin cc trng hp bnh nhng bin thin mc khu vc v t l mi mc lao Nhng gim st v phn tch ny l cn thit o lng tin b ca cc chng trnh mc tiu bnh thuc Mc tiu Pht trin Thin nin k (Hp 7.8).

Bng 7.3 lit k Mc tiu Pht trin Thin nin k s 6, nhm vo HIV/AIDS, st rt v cc bnh khc thng c hiu l cc bnh truyn nhim. Cc bnh khng truyn nhim chim phn ln t vong v tn tt hu ht cc nc v ang b b st. Cc ch bo, cc nh ngha v cc mc tiu chung cn phi t c i vi bnh lao (mc tiu 8) c trnh by trong bng 7.3; tt c u cn phi c gim st k lng. Bng 7.3. Mc tiu Pht trin Thin nin k s 6: Chng li HIV/AIDS, st rt v cc bnh khc
Mc tiu 8 S dng tng vo nm 2015 v bt u gim t l mi mc st rt v mt s bnh quan trng khc. Cc ch bo ca Lao (23 v 24 ca 48) T l hin mc v t l t vong ca bnh lao, t l cc trng hp lao c pht hin v iu tr khi theo chng trnh DOTS. Cc nh ngha S lng cc trng hp xt nghim dng tnh (trn 100.000 dn); s t vong do lao (tt c cc dng) trn 100.000 dn/nm; t l tt c cc trng hp lao c xt nghim dng tnh mi c c theo chng trnh DOTS trong mt nm no ; t l cc trng hp lao xt nghim dng tnh c ng k c iu tr thnh cng theo chng trnh DOTS. Cc mc tiu c th o lng c Ti nm 2015, gim t l hin mc xung 50% con s c tnh ca nm 2000; ti nm 2015, gim t l t vong xung 50% con s c tnh ca nm 2000; Ti nm 2005, t ti con s 70% pht hin bnh; ti nm 2005 t ti con s 85% iu tr thnh cng.

142 Chng 7

Hp 7.8. Cc mc tiu pht trin thin nin k (MDGs)

Cc nc thnh vin ca Lin Hp quc nht tr thng qua Tuyn b Thin nin k vo thng 9 nm 2000, t mc tiu vo nm 2015 t c cc mc tiu pht trin chung ny. Tm mc tiu pht trin thin nin k c pht trin nh l mt phn ca ca bn ng x i li gip cho vic thc hin Tuyn b Thin nin k. Cc mc tiu ny cp n cc vn ngho i, gio dc, bt bnh ng gii, t vong tr em, t vong m, HIV/AIDS v cc bnh truyn nhim quan trong khc, bn vng mi trng, v nhu cu hp tc ton cu trogn pht trin (xem http://millenniumindicators.un.org/unsd/mi/mi_goals.asp bit thm thng tin chi tit v cc mc tiu c th, mc ch v cc ch bo). D ch c ba mc tiu ch trng vo vn sc khe nhng tt c cc mc tiu u c lin quan cht ch ti sc khe. Cc mc tiu thin nin k nhn mnh n ngha v qua li gia cc nc c thu nhp cao v thu nhp thp v trung bnh.20 Cc mc tiu ny cho rng cc quan chc c trch nhim cung cp cc dch v sc khe, v gip nh ngha vai tr ca y t trong pht trin. Bng cch t ra cc mc ch nh lng v khuyn khch gim st tin b u n, cc mc tiu thin nin k duy tr nhn thc v nhu cu khn cp phi hnh ng. Mt trong nhng thch thc ny sinh ca cc Mc tiu thin nin k ny l o lng tin b. Nhng thng tin dch t hc xc thc thit yu theo di nhng tin b, nh gi tc ng v gn nhng thay i vi cc chng trnh can thip khc nhau, cng nh hng dn hnh ng theo quy m v trng tm ca chng trnh.

Cc yu t nh hng n tnh hiu qu ca cc h thng gim st c lit k trong bng 7.4 Bng 7.4. Cc yu t nh hng n hiu ca ca cc h thng gim st
Yu t hay thnh phn S lng iu kin Khi lng thng tin/ mi trng hp bnh Gnh nng cho ngi bo co Mi quan tm ca cc nh hoch nh chnh sch vi s liu gim st Cc mc tiu gim st Chin lc bo co cc vn nghim trng nhng ph bin Tnh hu ch ca s liu vi a phng ng dng b gii hn bi phn tch s liu v lu tr Tnh hu ch i vi nhng nh hoch nh chnh sch cho cc hnh ng d phng Hiu qu t hn t Nh Cao R rng v c th h tr c thng tin p ng cc mc tiu v i n quyt nh Cao S liu c s dng tot Cao Khng hiu qu Qu nhiu Qu nhiu Qu phc tp v cng knh Thp C th khng r rng Bo co phc tp Thp S dng s liu hn ch Thp

Cu hi
7.1. 7.2. 7.3. 7.4. 7.5. S ng gp ca bnh truyn nhim trn tng s t vong Brazil trong nhng nm 1930-2003 c trnh by Hnh 6.2. C th gii thch nh th no cho s thay i quan st c trong hnh ny? Nu bn l cn b y t tuyn huyn, bn s theo di s pht sinh bnh si v pht hin mt v dch trong huyn ca bn nh th no? Bn hy m t dy chuyn ly bnh cho v ng c thc n do salmonella. Hy bnh lun nhng tr ngi c th nh hng n tnh hiu qu ca Cc Quy nh Sc khe quc t sa i. S dng v d v bnh lao, hy m t bn cp d phng c nu Chng 6 v nhng hnh ng cn thit mi cp c c mt chng trnh d phng ph hp v ton din.

Cc bnh truyn nhim: gim st dch t hc v phn hi

143

Ti liu tham kho

1. World Health Statistics 2006. Geneva, World Health Organization, 2006. 2. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al. (eds).Disease control priorities in developing countries. New York, Oxford University Press, 2006. 3. Gottlieb MS, Schroff R, Schanker HM, Weisman JD, Fan PT, Wolf RA, et al. Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency. N Engl J Med 1981;305:1425-31. 4. Biggar RJ, Nasca PC, Burnett WS. AIDS-related Kaposis sarcoma in New York City in 1977. N Engl J Med 1988;318:252. 5. Olsen J, Saracci R, Trichopoulos D, eds. Teaching epidemiology. Oxford, Oxford University Press, 2001. 6. Snow J. On the mode of communication of cholera. London, Churchill, 1855 (Reprinted in Snow on cholera: a reprint of two papers. New York, Hafner Publishing Company, 1965). 7. SARS. How a global epidemic was stopped. Manila, World Health Organization. Regional Office for the Western Pacific, 2006. 8. Heymann D. Infectious Diseases. In: Detels R, McEwen J, Beaglehole R, Tanaka K. Oxford Textbook of Public Health. Oxford, Oxford University Press, 2005. 9. McMichael AJ, Campbell-Lendrum DH, Corvalan CF, Ebi KL, Githeko AK, Scheraga JD, et al. Climate change and human health, risks and responses. Geneva, World Health Organization, 2003. 10. Report on infectious diseases: removing obstacles to health development.Geneva, World Health Organization, 1999. 11. International Health Regulations 2005. Geneva, World Health Organization, 2006. 12. Baker MG, Fidler D. Global public health surveillance under new international health regulations. Emerg Inf Dis 2006;12:1058-65. 13. Avian influenza: assessing the pandemic threat. WHO/CDS/2005.29. Geneva, World Health Organization, 2005. 14. Epidemiology of WHO-confirmed cases of avian influenza A (H5N1) infection. Wkly Epidemiol Rec 2006;81:249-60. 15. Ungchusak K, Auewarakul P, Dowell SF, Kitphati R, Auwanit W, Puthavathana P, et al. Probable person-to-person transmission of avian influenza A (H5N1). N Engl J Med 2005;352:333-40. 16. Bres P. Public health action in emergencies caused by epidemics: a practical guide. Geneva, World Health Organization, 1986. 17. de Quadros CA. Can measles be eradicated globally? Bull World Health Organ 2004;82:134-8. 18. Shelton JD, Halperin DT, Wilson D. Has global HIV incidence peaked? Lancet 2006;367:1120-2. 19. Rehle T, Lazzari S, Dallabetta G, Asamoah-Odei E. Second-generation HIV surveillance: better data for decision-making. Bull World Health Organ 2004;82:121-7. 20. Haines A, Cassels A. Can the Millennium Development Goals be attained? BMJ 2004;329:394-7.

145

Chng 8 Dch t hc lm sng

Thng ip chnh
Dch t hc lm sng l ng dng ca cc nguyn l v cc phng php dch t vo thc hnh y hc. Vi s gia tng chi ph y t, thc hnh lm sng ang tr thnh mt ch ph bin ca nghin cu dch t. Cc hng dn da trn bng chng ci thin hiu qu lm sng. Tuy nhin, cc iu tr hiu qu khng c s dng y , v cc iu tr khng hiu qu, hoc tn km v khng cn thit vn ang c s dng.

Gii thiu
Dch t hc lm sng l ng dng cc nguyn l v phng php dch t hc vo thc hnh y hc lm sng. N thng lin quan n mt nghin cu c tin hnh trong mt bi cnh lm sng, hu ht bi cc thy thuc lm sng, vi cc bnh nhn l i tng ca nghin cu. Nguyn tc la chn nhng phng php c pht trin trong dch t v phi hp chng vi khoa hc ca y hc lm sng. Mc ch ca dch t hc lm sng l gip vic ra quyt nh trong xc nh cc trng hp bnh. Dch t hc lm sng bao gm cc phng php cc thy thuc lm sng s dng kim tra cc qu trnh v kt qu cng vic ca h l mt khoa hc y hc c bn. Do dch t hc lm vic vi cc qun th v y hc lm sng lm vic vi c th, iu ny gi rng dch t hc lm sng l mt s mu thun v t ng. Tuy nhin, dch t hc lm sng n gin quan tm n mt qun th bnh nhn xc nh hn l s dng qun th da trn cng ng. Cc mi quan tm chnh ca dch t hc lm sng bao gm: Cc nh ngha v s bnh thng v bt thng xc thc ca cc xt nghim chn on Lch s t nhin v tin lng bnh Hiu qu ca iu tr v, D phng trong thc hnh lm sng.

nh ngha s bnh thng v bt bnh thng

u tin hng u trong t vn lm sng l xc nh xem cc triu chng, du hiu hoc kt qu cc xt nghim chn on l bnh thng hay bt thng. Quyt nh ny cn phi a ra trc khi thc hin bt c iu tra no su hn hoc iu tr. Cng vic s d dng nu lc no cng phn bit c r rng gia cc o lng ca ngi bnh thng v khng bnh thng. Rt tic l ngi ta t thy nh vy, tr khi nhng ri lon gien c xc nh bi mt gen tri. Cc o lng ca cc bin s

146 Chng 8 lin quan n sc kho c th c din gii nh cc phn b tn s trong qun th bnh nhn. Him khi cc phn b tn s ca cc o lng bnh thng v bt thng l hon ton khc nhau, nhng iu thng thy hn l ch c mt phn b v ci gi l ngi khng chun nm pha cui ca phn b chun (xem Chng 4). C ba cch phn bit cc kt qu trong mt phn b nh vy: Bnh thng l thng thng Bt bnh thng kt hp vi bnh Bt bnh thng c th iu tr c.

Bnh thng l ph bin

nh ngha ny phn loi cc gi tr thng hay xut hin l bnh thng (normal) v nhng gi tr t khi xut hin l bt bnh thng (abnormal). Chng ta gi nh rng mt im ngng (cutoff point) (c xc nh mt cch ch quan) trong phn b tn s (thng l hai n v ca lch chun trn v di gi tr trung bnh, tc l cng, tr hai ln lch chun ca gi tr trung bnh) c coi l gii hn ca s bnh thng (normality), tt c cc gi tr vt ra ngoi khong ny u b coi l bt thng. Ngi ta gi l nh ngha thc t ca bt thng. Nu nh phn b l phn b Gausian (phn b chun theo ngha thng k) th im ngng ny s xc nh 2,5 % s ngi ca qun th l "bt thng". Mt cch tip cn khc trong trng hp khng phi l phn b thng k chun, l vic s dng im phn trm (bch phn v): chng ta coi im phn trm th 95 l ng phn chia bnh thng v bt thng, nh vy phn loi 5% ca qun th l "bt thng". Tuy nhin khng c c s sinh hc cho vic s dng im ngng ch quan nh mt nh ngha cho s bt bnh thng ca hu ht cc bin s. V d, khng c mi lin h lin tip gia huyt p tm thu v bnh tim mch (Hnh 8.1). Hnh 8.1. Cc mi lin quan gia huyt p v bnh tim v t qu1
Bnh tim 4 8 2 4 Xut huyt t qu

1 0.50 0.50

0.25 70 80 90 100 Huyt p tm trng (mm Hg) 110

0.25 110 120 130 140 150 160 Huyt p tm thu (mm Hg) 170

Thm ch trong cc gii hn bnh thng, nh c xc nh v mt thng k, c s tng nguy c mc bnh so vi cc mc thp hn. Nguy c l mt qu trnh c cp bc; khng c im ngng v ti nguy c bt u t ngt tng. Hu ht t vong do bnh mch vnh xut hin nhng ngi c mc cholesterol huyt thanh trung bnh trong qun th, v ch c mt t l nh t vong xy ra nhng ngi c ch s ny rt cao.

Dch t hc lm sng 147

S bt thng kt hp vi bnh
La chn th hai ny da vo s phn b ca cc o lng c ngi lnh ln ngi bnh, v chng ta c th c gng xc nh im ct thch hp phn chia r rt hai nhm. S so snh hai phn b tn s cho thy c s trng lp ng k, iu ny c minh ha bng phn b cholesterol huyt thanh nhng ngi b v khng b bnh mch vnh. Vic xc nh im ct phn chia r rt hai nhm c bnh v khng c bnh r rng l khng th c (xem Hnh 6.7). S lun lun c mt s ngi khe mnh bn pha bt thng ca im ct, h c gi l bt thng v s c mt s trng hp b bnh tht bn pha bnh thng. Hai loi sai s phn loi ny c th hin thng qua ch s nh lng l: nhy v c hiu ca xt nghim nh tho lun trong Chng 6. nhy l t l thc s b bnh trong s nhng trng hp xt nghim xc nh l bt thng (bnh). c hiu l t l thc s khng b bnh trong s nhng trng hp xt nghim xc nh l bnh thng. Lun lun phi cn bng gia nhy v c hiu, tng ch s ny s lm gim ch s kia.

Bt thng c th iu tr c
Nhng kh khn trong vic phn bit chnh xc gia bnh thng vi bt thng dn ti vic dng cc tiu chun c xy dng da vo kt qu ca nhng th nghim lm sng c kim sot bng phn b ngu nhin, nhng th nghim c thit k pht hin im m ti vic iu tr c li nhiu hn c hi. ng tic l rt nhiu quyt nh iu tr c a ra m khng c nhng bng chng nh vy. iu tr huyt p cao l mt v d tt cc th nghim lm sng sm cung cp bng chng vng chc rng iu tr huyt p tm trng rt cao (> 120mmHg) l c hiu qu. Nhng th nghim tip theo cho thy rng iu tr mc huyt p tm trng thp hn, nh 90 mmHg, th c li hn. Tuy nhin, cc th nghim ny thng c thit k cha tnh n cc yu t nguy c khc hoc chi ph ca iu tr. Cc nghin cu chi ph hiu qu phc tp hn c th tnh n cc hu qu kinh t ca iu tr vo cc quyt nh lm sng. Chng ta c th xc nh cc mc huyt p m ti vic iu tr s c ngha c v mt kinh t ln y hc cho nam v n gii cc nhm nguy c c bit. iu tr mt ph n tr vi mc huyt p tm trng l 90mmHg, ngi ny c nguy c bnh tim mch thp, s t hiu qu v chi ph hn iu tr mt nam gii ln tui hn vi huyt p tm trng 90mmHg, ngi c nguy c bnh tim mch cao hn nhiu. Tuy nhin, nu iu tr ngi ph n tr khng c tc dng ph no ngoi tr chi ph, c ta c th la chn t tr tin.2 Nhng tnh trng coi l ng c iu tr thay i theo thi gian; Hnh 8.2 cho thy s thay i nh ngha ca cc mc c th iu tr c ca cao huyt p. Do cc th nghim lm sng thu thp nhng bng chng mi, cc khuyn ngh iu tr c xu hng thay i. Tuy nhin, ti mi thi im m mt im ct mi c xut, chng ta cn xem xt v mt hu cn v chi ph. V d, nu chng ta s dng cch tip cn da trn bng chng iu tr nhng ngi b cao huyt p nh, chng cn quan tm hn n nh gi nguy c tuyt i (hoc nn) ca bnh tim mch, v nhn mnh t hn n huyt p thc ca h.3 D on nguy c nh vy c th gip cc thy thuc lm sng truyn t cho bnh nhn (Hp 8.1)

148 Chng 8 Hnh 8.2. iu tr cao huyt p: thay i tiu ch theo thi gian

Hp 8.1. D on nguy c
D on nguy c (nh ngha nguy c tuyt i ca mt s kin theo mt giai on thi gian c bit) cung cp cho cc thy thuc lm sng cc o lng tuyt i hiu qu ca iu tr v gip h trong vic a ra cc quyt nh iu tr. S d on nguy c c th c s dng gii thch cho cc yu t nguy c a dng.4 V d, mt nguy c mc bnh tim mch 5 nm ca cc vn sng cn hoc khng sng cn c xc nh bi tui, gii, tnh trng bnh tiu ng, tin s ht thuc l, huyt p tm thu v lng cholesterol ton phn ca mt ngi. Nguy c mc bnh tim mch chung ca mt c th c th c tnh t mt s d on nguy c. Xem v d trang http://www.nzgg.org.nz/CVD_risk_Chart.pdf.

Cc xt nghim chn on
Mc tiu u tin ca lm sng l chn on bt c bnh no m c th iu tr c. Mc tiu ca xt nghim chn on l gip khng nh cc chn on c a ra da vo cc du hiu v triu chng ca ngi bnh. Trong khi cc xt nghim chn on thng bao gm cc xt nghim (gen, vi sinh, sinh ha hay sinh l), th nhng nguyn tc gip xc nh gi tr ca cc xt nghim ny cng phi c s dng vo vic nh gi gi tr chn on ca cc triu chng, du hiu.

Gi tr ca mt xt nghim
Bnh c th c hoc khng, v xt nghim c th dng tnh hay m tnh. V vy c 4 kh nng t hp v bnh v kt qu xt nghim c trnh by Hnh 8.3 v c m t trong mi lin quan vi cc xt nghim sng tuyn Chng 6.

Dch t hc lm sng 149

Hnh 8.3: Mi lin h gia kt qu chn on v s xut hin ca bnh

Trong hai tnh hung, xt nghim tr li ng (dng tnh tht v m tnh tht) v trong hai tnh hung khc, xt nghim tr li sai (dng tnh gi v m tnh gi). Chng ta ch c th s dng nhng phn loi ny khi c mt phng php chnh xc tuyt i xc nh tnh trng c bnh hay khng c bnh, da vo chng ta c th xc nh tnh xc thc ca nhng xt nghim khc. Him khi c mt phng php nh vy tn ti, c bit khi cc bnh khng ly nhim mn tnh c quan tm. Vi l do ny, v bi v cc xt nghim hon ton chnh xc thng rt t v i hi can thip t bn ngoi, cc xt nghim n gin v r tin hn c s dng trong thc hnh lm sng hng ngy. Thm ch sau , chng ta vn cn bit v gii thch cho tnh gi tr, xc thc v chnh xc ca nhng xt nghim ny khi din gii cc kt qu. xc nh tnh ng dng thc tin ca mt xt nghim no , chng ta cn bit nhiu hn v cch thc hin nh th no. Gi tr d on dng tnh v m tnh l c bit quan trng. Gi tr d on dng tnh l xc xut c bnh ca mt bnh nhn c kt qu xt nghim dng tnh, trong khi gi tr d on m tnh l xc xut mt ngi khng c bnh khi c kt qu xt nghim m tnh. Gi tr d on ph thuc vo nhy v c hiu ca xt nghim v quan trng nht l t l hin mc ca bnh trong qun th c xt nghim. Thm ch vi nhy v c hiu cao (Chng 6), nu t l hin mc thp th gi tr d on dng tnh ca mt xt nghim c th rt thp. Cc gi tr d on dng tnh v m tnh ca mt xt nghim trong thc hnh lm sng ph thuc ch yu vo t l hin mc bnh ca nhng ngi c xt nghim; iu ny khc so vi t l hin mc mt nghin cu c cng b v s hu ch ca xt nghim.

Lch s t nhin v tin lng

Thut ng lch s t nhin ca mt bnh l ni n nhng giai on ca mt bnh bao gm: Giai on bnh bt u; Giai on tin triu chng: t khi bt u s bin i bnh l n khi xut hin triu chng hay du hiu u tin; Giai on bnh biu hin r rt v lm sng v bnh c th thuyn gim, ti pht hoc khi hay din bin ti t vong.

150 Chng 8 S pht hin v iu tr bt k giai on no cng lm thay i lch s t nhin ca bnh, nhng ch c th xc nh c hiu qu ca iu tr nu bit c din bin t nhin ca bnh khi khng iu tr.

Tin lng
Tin lng l d on din bin ca bnh sau khi mc bnh v c th hin bng xc xut ca s vic c th s xy ra trong tng lai. Cc d on da vo nhng nhm bnh nhn xc nh v kt qu c th hon ton khc i vi nhng bnh nhn ring r. Tuy nhin, s hiu bit v kh nng tin lng gip cho vic xc nh phng php iu tr tt nht. Yu t tin lng l nhng c tnh lin quan vi hu qu sc khe ca bnh nhn mc bnh c cp. V d, bnh nhn nhi mu c tim cp tnh, tin lng c lin quan trc tip vi chc nng ca c tim. Cn c nhng thng tin dch t hc t nhiu bnh nhn d on tin lng v kt qu. Ring kinh nghim lm sng th khng v thng da vo mt s t bnh nhn v c theo di khng y . V d, nhng bnh nhn n khm bc s th khng i din cho tt c cc bnh nhn ca mt bnh c bit no . Ngi bnh c th c la chn da vo tnh trng nng nh hoc cc c trng khc ca bnh, hoc theo cc c im v nhn khu, x hi hoc c nhn ca h. Hn na, v nhiu bc s khng theo di bnh nhn mt cch c h thng, nn h c nhn nh hn ch v thng bi quan v tin lng bnh. Mt quan st lm sng v ci thin tin lng theo thi gian c th c thc v nh vic iu tr tt hn, nhng n cng c th l do gi to v s gia tng nhng trng hp bnh nh c nhn iu tr. Nghin cu dch t hc c thit k tt c th a ra nhng thng tin ng tin cy v tin lng bnh.

Cht lng cuc sng

nh gi tin lng mt cch l tng l phi bao gm nhng o lng tt c cc kt qu lm sng tng ng, khng ch l t vong, v ngi bnh thng ch n nhng vn v cht lng cuc sng khi h ang sng. Trong cc nghin cu xc nh lch s t nhin v tin lng bnh, nn chn nhm bnh mt cch ngu nhin, nu khng th nhng sai s do la chn c th nh hng nghim trng n cht lng thng tin thu c. V d, tin lng cho nhng bnh nhn au ngc nm iu tr bnh vin c v nh xu hn nhng bnh nhn au ngc do cc nhn vin y t cng ng khm.

S lng cuc sng

Tin lng v t vong c o lng bng t sut t vong theo trng hp bnh, hay kh nng sng st. C ngy khi bnh v thi gian theo di phi c xc nh r rng. Phn tch kh nng sng st (survival analysis) l mt phng php xc nh tin lng n gin. Nhng kh nng sng sau nhi mu cp tnh c theo di trnh by Hnh 8.4. Phn tch kh nng sng c tin hnh trn cc nhm la chn, v d nhng bnh nhn vn cn sng sau khi pht bnh mt thng. Nhiu trng hp nhm thun tp sau ny (199192) sng thm hn 3 nm sau khi b nhi mu c tim khi so snh vi nhng trng hp tng t trong thi gian 10 nm trc y, iu ny cho thy nhng thnh qu ca phng bnh cp hai i vi tnh trng nhi mu c tim.6 Phn tch bng sng (lifetable analysis) l mt phng php phc tp hn trong vic d on s xut hin cc s kin theo thi gian cho nhng bnh nhn c nguy c b bnh da trn cc m hnh bnh trc y. Khi theo di nhm thun tp nhng bnh nhn tin lng, cc sai lch c th ny sinh do phng php la chn ban u v do s theo di khng y .

Dch t hc lm sng 151

Hnh 8.4: Xc xut sng sau nhi mu c tim ( sng c t nht 28 ngy sau s kin), Auckland, 198384, 198788, 1991926

Hiu qu iu tr
Mt vi phng php iu tr c u im r rt nn khng yu cu nhng ch s nh gi chun mc; iu ny ng vi v d dng khng sinh cha vim phi v phu thut iu tr chn thng. Tuy nhin, nhng trng hp r rng ny tng i him trong y hc lm sng. Ni chung, hiu qu iu tr thng khng r rng v phn ln cc can thip cn phi nghin cu nh gi hiu qu. Nhng iu tr c hiu cn phi cho thy mang li li ch nhiu hn l tc hi gy ra cho bnh nhn, nhng ngi thc s s dng chng: iu ny c gi l tnh hiu lc. Cc bin php iu tr cng cn phi mang li li ch nhiu hn tc hi gy ra cho tt c nhng bnh nhn c yu cu iu tr: do khng phi tt c mi ngi s thc s s dng bin php iu tr m h c ch nh, vic tnh n nhng hu qu ca vic khng s dng iu tr l rt quan trng. Vic nghin cu tnh hiu lc c d dng hn khi gii hn nghin cu nhng bnh nhn c tnh tun th. Tnh tun th iu tr l ngi bnh thc hin ng cc y lnh do thy thuc a ra. Hiu qu thc t c xc nh thng qua cc nghin cu v kt qu ca mt nhm ngi c p dng mt bin php iu tr no , tuy nhin trong nhm ny th ch c mt s ngi tun th phng php iu tr. Phng php tt nht trong o lng hiu lc v hiu qu l trin khai th nghim lm sng ngu nhin c i chng, nh c cp nhng chng trc. Tuy nhin, c nhiu tnh hung m th nghim lm sng ny khng th thc hin c, ch c mt t l nh ca cc can thip y t hin hnh c th c nh gi thng qua phng php ny. Vic cc hng dn lm sng da trn bng chng sn c tt nht l hon ton c kh nng do s lng ngy cng tng ca cc th nghim c thit k tt.

152 Chng 8

Hp 8.2. Nhiu li ch hn tc hi?

Cc li ch ca aspirin vi bnh nhn mc bnh tim mch c xc nh, nhng vai tr ca aspirin km r rng hn trong d phng cp mt, c bit ph n. Mc d vy, mt s hng dn cho cc thy thuc lm sng gi s dng aspirin liu thp cho ph n, nhng ngi c nguy c 10 nm mc bnh mch vnh ln u vt qu 20%. Tuy nhin, mt phn tch tng hp (metaanalysis) trn 6 th nghim phn b ngu nhin c i chng, bao gm 51.342 ph n (v 44.114 nam gii) vi nguy c mc bnh tim mch thp, nhng ngi c theo di trung bnh trong 6,4 nm, cho thy khng c hiu qu i vi nguy c t vong do bnh mch vnh v hay tim mch, mc d nguy c t qu gim n 17% (t s chnh OR: 0,83; khong tin cy 95%: 0,70,97). ng thi, aspirin lm tng nguy c chy 7 mu (OR:1,68; 95% khong tin cy: 1,132,52).

S dng cc hng dn da trn bng chng

Cc hng dn l cc ghi nhn c bin son mt cch h thng hoc nhng khuyn ngh gip cc thy thuc lm sng v bnh nhn trong vic ra quyt nh v chm sc y t ph hp cho nhng trng hp lm sng c th.8 Vic t bng chng vo thc hnh i hi cc hng dn da trn bng chng. Trong khi c rt nhiu hng dn, chng khng nht thit phi c s dng ht trong thc thnh. Thc s, c bng chng gi rng rt nhiu bnh nhn, thm ch cc nc thu nhp cao, hin khng c nhn iu tr da trn bng chng tt nht.9,10 Tnh trng ny c bit km nhng nc km pht trin. Trong mt nghin cu trn 100.000 bnh nhn t 10 nc thu nhp thp v trung bnh, 20% bnh nhn mch vnh khng c nhn aspirin v khong mt na khng c thuc chn , nhng loi thuc rt r v sn c nhiu ni.11 Hp 8.3. Pht trin v s dng hng dn lm sng
Hng dn lm sng nhm nng cao cht lng chm sc sc khe thng qua: Khuyn co iu tr r rng Tiu chun nh gi thc hnh lm sng Gio dc v o to chuyn gia y t H tr bnh nhn ra quyt nh chnh xc Nng cao s trao i gia bnh nhn v chuyn gia y t Vin sc khe v lm sng trung ng (The National Institute for Health and Clinical Excellence NICE) cung cp nhng hng dn lm sng v cch iu tr ph hp cho tng bnh c th trong Dch v y t quc gia Anh. NICE pht trin nhng hng dn v y t cng cng, k thut y t v thc hnh lm sng.

Cc hng dn da trn bng chng ca nhiu bnh hin sn c nhiu ni (v d xem trang: http://www.guideline.gov), v cc hng dn thch hp vi cc hon cnh a phng hoc quc gia ring bit cng c cung cp. Cch tip cn thc hin cng c th v tp trung th thc hnh cng c nhiu kh nng theo cc khuyn ngh ca bn hng dn. V d, ch n gin cung cp cc thng tin v cc hng dn th c t tc ng, nhng kt ni chng vi cc hi tho hoc lp o to v cung cp nhng gi trong cc h s y t th c tc dng thay i thc hnh hn nhiu. Cng cn ch rng rt nhiu hng dn c pht trin cho cc nc thu nhp cao kh kh thi ngay cc nc thu nhp thp v trung bnh. Cc hng dn quc gia

Dch t hc lm sng 153

c bit c th gip cc hn ch thc hnh nh bn thuc khng c k n bi nhng ngi c th c li ch kinh t t vic bn nhng mt hng nht nh.13 C ti 70% chi ph cho thuc men c th khng cn thit mt s quc gia.

D phng trong thc hnh lm sng

Nhng hiu bit su sc v dch t hc gip cho cng tc d phng trong thc hnh lm sng thng thng. Hu ht cc hot ng d phng ny l d phng cp hai v cp ba, nhng d phng cp mt vn c th c p dng trong cc hot ng c bn (xem Chng 6). Cc thy thuc nhi khoa nhn thc c iu ny qua mt thi gian di tham gia vo cc chng trnh tim chng m rng, sng tuyn nhng d tt bm sinh v chuyn ha nh phenylxeton niu, thng xuyn cn tr v s dng biu pht trin chun mc. Chm sc trc sinh cng l mt v d na v s lng ghp cng tc d phng vo thc hnh lm sng thng ngy. Hnh 8.5: Ghi chp ca vic ngng ht thuc sau 1 nm theo di.14

Gim cc yu t nguy c
Cc bc s, cc nha s v cc nhn vin y t khc c kh nng thuyt phc t nht mt s trong s cc bnh nhn ca h khng ht thuc na. Mt th nghim c i chng v cc can thip phng chng thuc l khc nhau trong thc hnh chung cho thy, cc li khuyn thng ngy v vic s dng thuc l l hu ch, v hiu qu ca n c th c chng minh vi mt lot cc bin php (Hnh 8.5). Ti mt s nc, khong 60% nhng ngi hin ang s dng thuc l cho bit h c nhn li khuyn b thuc t cc bc s ca h.15 Cc thy thuc lm sng c th ci thin nhng n lc ca h thuyt phc cc bnh nhn ngng ht thuc bng cch: Tng cng cht lng can thip Tp trung vo nhng ngi ht sn sng b thuc

154 Chng 8 Tng tn s li khuyn cho cc bnh nhn Lin kt vi cc knh can thip phng chng thuc l khc C rt nhiu c hi khc cho cc chuyn gia y t a ra nhng t vn thc t v gip bnh nhn vi hi vng ngn nga nhng bnh mi hoc lm gim s trm trng ca nhng bnh hin tn ti. Cc nh dch t hc lm sng lin quan thng xuyn n vic tnh ton nhng hiu qu ca cc can thip.

Gim cc yu t nguy c bnh nhn cc bnh xc nh

Vi cc bnh tim mch v tiu ng, phng php da trn bng chng gim nguy c c nhng hu qu xu bnh nhn cng tng t nh phng php gim nguy c xut hin bnh. S khc bit c bn l nguy c ca cc s kin lm sng trong tng lai ln hn rt nhiu khi bnh c hnh thnh. C can thip hnh vi v dc l u cho thy tc ng n tin lng ca nhng bnh ny.

Can thip hnh vi

Bao gm khuyn khch b thuc, tng cng hot ng th lc, thay i ch n v gim cn. Phi hp vi nhau c th t c s gim nguy c ti hn 60% nhng ngi mc bnh tim mch, v gp phn t c kim sot ng mu nhng ngi mc tiu ng.16

Can thip dc l
Vi nhng ngi mc bnh tim mch, cc hng dn can thip khuyn ngh iu tr lu di nguy c ng mu, huyt p cao v cholesterol cao. Phi hp aspirin, chn , c ch men chuyn angiotensin v statins c cho rng c th gim nguy c lp li nhi mu c tim ti 75%.17 Tuy nhin, c khong cch ln v iu tr gia cc quc gia, mt phn bi v chi ph v s phc tp ca vic s dng nhiu loi thuc v nhng cn tr khc i vi vic tip cn. Mt s vn ny c th c gii quyt bng vic s dng liu php phi hp liu c nh (Hp 8.4). Dch t hc lm sng r rng ng gp vo vic ci thin thc hnh lm sng. Tuy nhin, cc hiu qu iu tr khng c s dng y v khng hiu qu hoc tn km v cc iu tr khng cn thit vn c tin hnh rng ri. Cn rt nhiu iu m cc nh dch t hc c th lm ci thin thc hnh lm sng. Hp 8.4: Liu php phi hp liu c nh
Cc liu php phi hp liu c nh l mt phn chun ca iu tr HIV/AIDS, lao v st rt. Nhng liu php ny cho thy s ci thin dung np v hiu qu lm sng, v lm n gin s phn b v d tr. Mt khc, mt liu php phi hp liu c nh c khuyn ngh cho nhng ngi c nguy c bnh tim mch cao.17 Cc sn xut phn nh polipill c th rt r. Vi nhng ngi bnh tim mch cc nc thu nhp thp v trung bnh, tip cn vi chm sc d phng thng ph thuc vo kh nng chi tr ca h, v phn ln ngi khng c phc v ny cn thu n li ch t cng thc r tin v thun tin ny.

Can thip khc

C rt nhiu can thip khc qun l nhm bnh nhn nguy c cao hoc iu tr nhng bnh nhn c bnh. Can thip ny bao gm thay i mi trng gim phi nhim vi cc thnh phn gy d ng v cc yu t nguy c khc, k thut qun l stress, t vn v cc can thip phu thut.

Dch t hc lm sng 155

Cu hi
8.1. Ti sao t "dch t hc lm sng" li c mu thun v thut ng? 8.2. nh ngha thng c s dng ca s bt thng trong mt th nghim lm sng cn c vo tn s phn b ca cc gi tr xut hin trong mt qun th. Nhng hn ch ca nh ngha ny l g? 8.3. Trong bng di y, cc kt qu ca mt xt nghim chn on mi v bnh ung th c so snh qui trnh chn on hon chnh hin ang s dng. nhy v c hiu ca xt nghim mi l g? Cc bn c th khuyn ngh vic ng dng xt nghim mi khng? 8.4. Gi tr d on dng tnh ca xt nghim ny l bao nhiu? 8.5. Lit k ba u im chnh ca cc th nghim ngu nhin c i chng v kha cnh gip mt thy thuc lm sng gii thch vi mt bnh nhn v tm quan trng ca mt hiu qu iu tr. 8.6. Cc thng tin sau l kt qu ca phn tch tng hp7 v tc ng ca aspirin trong d phng cp 1 cc bnh tim mch chnh ph n c m t trong Bng 8.2: Cc trng hp bnh/ton b nhm iu tr (aspirin): 682/25.694 Cc trng hp bnh/ton b nhm chng (gi dc): 603/25.648 T s chnh OR (95% khong tin cy): 0,88 (0,790,99) Gim nguy c tng i: RRR = (TC/T) Gim nguy c tuyt i: ARR = (TC) S lng cn iu tr: NNT = (1/ARR)

Hy tnh cc ch s sau t thng tin trn: a. b. c. d. e. T sut mc bnh trong nhm iu tr T sut mc bnh trong nhm chng S gim nguy c tng i S gim nguy c tuyt i S lng ph n cn s dng aspirin liu thp phng nga mt bnh tim mch trong 6,4 nm (NNT) f. S lng ph n cn s dng aspirin liu thp trong 1 nm ngn nga mt bnh tim mch g. Li ch tuyt i trung bnh (hoc s lng cc ca bnh tim mch m liu php aspirin c th ngn nga tn 1000 ph n). 8.7. Lit k mt s gii hn tim tng ca phn tch tng hp c cp trong nghin cu Hp 8.2 8.8. Da trn kt qu phn tch mta ny, bn mong i thy thuc lm sng s c khuyn ngh g n vic quan tm s dng aspirin ph n.
Bnh c chn on (tnh trng bnh thc s) C bnh Xt nghim mi Dng tnh m tnh 8 2 Khng bnh 1000 9000

156 Chng 8

Ti liu tham kho

1. The World Health Report. Reducing Risks, Promoting Healthy Life. Geneva, World Health Organization, 2002. 2. Jackson RT. Guidelines for managing raised blood pressure: Evidence based or evidence burdened? BMJ 1996;313:645. Medline 3. Jackson R, Barham P, Bills J, Birch T, McLennan L, MacMahon S, et al. The management of raised blood pressure in New Zealand. BMJ 1993;307:10710.Medline 4. Manuel DG, Lim J, Tanuseputro P, Anderson GM, Alter DA, Laupacis A, et al. Revisiting Rose: strategies for reducing coronary heart disease. BMJ 2006;332:65962. Medline doi:10.1136/bmj.332.7542.659 5. Altman DG, Bland JM. Statistics Notes: Diagnostic tests 2: predictive values. BMJ 1994;309:102. Medline 6. Stewart AW, Beaglehole R, Jackson R, Bingley W. Trends in 3year survival following acute myocardial infarction 198392. Eur Heart J 1999;20:8037. Medline doi:10.1053/euhj.1998.1401 7. Berger JS, Roncaglioni MC, Avanzini F, Pangrazzi I, Tognoni G, Brown DL. Aspirin for the primary prevention of cardiovascular events in women and men: a sexspecific metaanalysis of randomized controlled trials. JAMA 2006;295:30613. Medline doi:10.1001/jama.295.3.306 8. Field MJ, Lohr KN, eds. Guideline for clinical practice from development to use. Washington, DC, National Academy Press, 1992. 9. Guide for guidelines: a guide for clinical guideline development. Brussels, In ternational Diabetes Federation, 2003. (http://www.idf.org/home/index.cfm?node=1044). 10. Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current evi dence and future implications. J Contin Educ Health Prof 2004;24:S317. Medline doi:10.1002/chp.1340240506 11. Mendis S, Abegunde D, Yusuf S, Ebrahim S, Shaper G, Ghannem H, et al. WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO PREMISE) (WHOPREMISE (Phase I) Study Group). Bull World Health Organ 2005;83:8208. Medline 12. Garg AX, Adhikari NK, Mcdonald H, RosasArellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293:122338. Medline doi:10.1001/jama.293.10.1223 13. Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: can low income countries escape the medical poverty trap? Lancet 2001;358:8336. Medline doi:10.1016/S01406736(01)05975X 14. LloydJones DM, Leip EP, DAgostino R, Beiser H, Wilson PW, Wolf PA, Levy MI. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 2006;113;791789. 15. Jamrozik K, Vessey M, Fowler G, Wald N, Parker G, Van Vunakis Hnh Controlled trial of three different antismoking interventions in general practice. BMJ 1984;288:1499503. Medline 16. Murray CJ, Lauer JA, Hutubessy RC, Niessen L, Tomijima N, Rodgers A, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular disease risk. Lancet 2003;361:71725. Medline doi:10.1016/S01406736(03)126554 17. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003;326:141924. Medline doi:10.1136/bmj.326.7404.1419

157

Chng 9

Dch t hc mi trng v ngh nghip

Thng ip chnh
Mi trng chng ta ang sng v lm vic c tc ng rt ln n s xut hin bnh tt v chn thng. Phi nhim vi cc yu t mi trng c xc nh bng liu lng, loi o lng thit lp mi quan h liu lng hu qu v liu lng p ng. nh gi tc ng sc khe a ra nhng ch bo cho tc ng sc khe tim tng ca nhng can thip quan trng. Dch t hc chn thng c s dng xc nh nhng bin php phng chng c nhiu kh nng hiu qu nht.

Mi trng v sc khe
Mi trng ca con ngi bao gm nhng yu t c bn nht: khng kh cho chng ta th, nc cho chng ta ung, thc phm cho chng ta n, thi tit bao quanh chng ta v khng gian cho chng ta vn ng. Ngoi ra, chng ta cng tn ti trong mi trng x hi v vn ha, mt mi trng c vai tr cc k quan trng i vi sc khe v th cht v tinh thn ca chng ta. Hu ht cc tnh trng bnh l do cc yu t mi trng gy ra hoc tc ng n. Chng ta cn hiu c cch m cc yu t mi trng c th tc ng n sc khe thit k c cc chng trnh phng chng hiu qu. Dch t hc mi trng l c s khoa hc cho vic nghin cu v gii thch mi lin quan gia mi trng v sc khe ca qun th. Dch t hc ngh nghip quan tm c th n cc yu t mi trng ti ni lm vic. Chn thng chu s tc ng rt ln bi cc yu t trong mi trng sng v lm vic nhng cng chu nh hng rt nhiu bi cc yu t hnh vi. Trong ngn ng thng dng, cm t tai nn thng ch nhng s kin khi chn thng xy ra, nhng c th dn n s hiu lm khi m t tai nn ch nhng s kin ngu nhin hn l mt tp hp ca nhng yu t cn nguyn c th d on c. Trong chng ny, chng ta s s dng cm t mi trng vi ngha rng hn bao gm tt c cc yu t bn ngoi c th c th dn n bnh tt hoc chn thng. Cc yu t mi trng khc nhau m c nh hng n sc khe c trnh by trong bng 9.1.1 Lnh vc sc khe mi trng v ngh nghip bao gm nhiu yu t cn nguyn c th m t theo h thng th bc nguyn nhn c gii thiu Chng 5. C th phn tch yu t nguy c gin tip theo khung l thuyt DPSEEA nh hnh 5.5 gia yu t giao thng v sc khe. Hnh 9.1 l h thng th bc nguyn nhn i vi sc khe mi trng v bnh ngh nghip.

158 Chng 9

Bng 9.1. Nhng yu t mi trng c th nh hng n sc khe

Yu t Tm l Sinh hc Mi trng bn ngoi Tai nn Ha cht V d Stress, tht nghip, lm ca, mi quan h Vi khun, vi rt, sinh vt k sinh Kh hu, ting n, bc x, ergonomics (iu kin, t th lm vic) Tnh hung bt ng, tc , tc dng ca ru, ma ty Thuc l, ha cht, bi, cht kch thch d ng da, cht ph gia trong thc phm

Tc ng ca phi nhim vi cc yu t mi trng

Cc tnh ton v gnh nng bnh tt ton cu cho thy mc nh hng ca cc yu t mi trng n sc khe. Khong 25 n 35% gnh nng bnh tt ton cu c th l do phi nhim vi cc yu t mi trng.2, 3 Cc vn sc khe ch yu l do lin quan n nc ung v tnh trng v sinh khng m bo, nhim khng kh trong nh do s dng nng lng un nu v si m, v nhim khng kh th do phng tin c gii v c s nng lng.

Gnh nng cc nc thu nhp thp

Gnh nng bnh tt do mi trng cc nc thu nhp thp ln hn rt nhiu so vi cc nc thu nhp cao, mc d vi mt s bnh khng truyn nhim, nh cc bnh mch vnh v ung th, gnh nng bnh tt theo u ngi cao hn nhng nc thu nhp cao. Tr em phi chu gnh nng t vong ln nht, vi hn 4 triu trng hp t vong mi nm do cc yu t mi trng, ch yu cc nc ang pht trin. T l t vong s sinh do cc nguyn nhn mi trng nhng nc thu nhp thp cao gp 12 ln so vi nhng nc thu nhp cao, phn nh mc ci thin c th t c nu c sng trong mi trng c li cho sc khe. Hp 9.1. H thng th bc nguyn nhn trong sc khe mi trng v bnh ngh nghip 1
ng lc ng sau xu hng sc khe v mi trng hin nay: Bin ng dn s th ha Ngho i v cng bng Khoa hc v k thut Xu hng tiu th v sn xut S pht trin kinh t Hnh vi con ngi chnh tc ng n cht lng mi trng: Rc thi tiu dng Nc sch S dng t ai v pht trin nng nghip Cng nghip ha Nng lng Mi trng km cht lng: phi nhim v nguy c: nhim mi trng Thc phm

Dch t hc mi trng v ngh nghip 159

t Nh Mi trng lm vic Mi trng ton cu

a nguyn nhn
Trong cc nghin cu dch t v cc yu t mi trng, mi yu t thng c phn tch ring bit. Tuy nhin, cn phi ch rng c nhiu cch khc nhau cc yu t mi trng c th tc ng ln nhau. a nguyn nhn v mt h thng th bc nguyn nhn r rng l bng chng gii thch cho s khc bit gia cc kt qu nghin cu dch t hc mi trng tin hnh nhng a im khc nhau. Tc ng ca cc yu t mi trng ln mi c nhn cn ph thuc vo nguy c phi nhim v cc c im c nhn, nh: Tui v gii Yu t di truyn Tnh trng bnh c im dinh dng C tnh Tnh trng th cht

Dch t hc bnh ngh nghip thng quan tm n qun th ngi trng thnh tui thanh nin hoc trung nin v thng l nam gii. Ngoi ra, trong dch t hc bnh ngh nghip, nhng ngi c phi nhim nhiu nht thng l khe mnh, t nht l vo thi im h bt u cng vic. Ngc li, nghin cu dch t v cc yu t mi trng ni chung thng bao gm c tr em, ngi cao tui v nhng ngi m yu. Nhng ngi c phi nhim trong qun th chung thng c xu hng nhy cm hn vi cc yu t mi trng so vi nhng ngi lao ng. iu ny rt quan trng khi kt qu ca cc nghin cu dch t hc bnh ngh nghip thng dng a ra tiu chun an ton cho tng nguy c mi trng c th. V d, tc ng do phi nhim vi ch xy ra tr mc thp hn so vi ngi ln (Bng 9.2). Mc ch trong mu l phng php c chp nhn o lng tnh trng phi nhim v cc mc lit k trong bng cho hai tnh trng sc khe l mc ti thiu qun th cn bo v c khi nhng tnh trng . Mc m cc chc nng chi phi hnh vi ca thn kinh tr em bt u bin i cn c th thp hn gi tr 100 g/l trnh by trong bng 4. Bng 9.2: Mc ch trong mu (g/l) thp nht m ghi nhn c nhng tc ng ln sc kho tr v ngi ln 5, 6
Tc ng Gim mc heamoglobin Thay i chc nng chi phi hnh vi ca thn kinh Tr em 40 25 Ngi trng thnh 50 40

nh gi cc bin php phng chng

ngha chnh ca dch t hc mi trng v bnh ngh nghip l nghin cu nguyn nhn gy bnh. Cc bin php phng chng c th nhm gim phi nhim v cc tc ng i vi sc khe ngh nghip cng cn phi nh gi. Phi nhim vi cc yu t mi trng c hi thng l hu qu ca cc hot ng cng nghip hoc nng nghip nhm em li li ch kinh t cho cng ng, nhng chi ph loi b nhng

160 Chng 9 phi nhim ny li c th rt ng k. Ngoi ra, nhim mi trng thng rt tn km v c tc ng xu n t nng nghip, ti sn cng nghip cng nh sc khe con ngi. Cc phn tch dch t hc, nh gi tc ng kinh t v cc phn tch chi ph hiu qu s gip cho nhng ngi c thm quyn cn nhc c gia nhng nguy c v sc khe v nhng chi ph cho vic phng chng.

Gi tr ca phng chng
V d v cc phn tch dch t v kinh t kt hp ch ra nhng gi tr tim tng ca vic phng chng.7 i vi ba bnh nhim xy ra trong nhng nm 60 Nht Bn, cc tnh ton (Bng 9.3) cho thy phng chng s t tn km hn so vi vic cha tr nhng bnh ny.8 Chi ph bao gm n b cho nn nhn v lm sch mi trng, so vi chi ph c tnh cho vic kim sot nhim nhm phng chng nhng bnh ny. T s li chchi ph l 100 i vi nhim thy ngn v bnh Minamata (Bng 9.2).

Nhng thch thc trong tng lai

Dch t hc mi trng s i mt vi nhng thch thc mi trong nhng thp k ti do s bin i kh hu ton cu. Cn c nhng nghin cu v tc ng sc khe do bin i kh hu ton cu, l thng tng ozone, tia cc tm, ma axt v cc vn di bin ng dn s.9 Nhng tc ng sc khe tim tng do bin i kh hu vn cha c cc nghin cu dch t hc bo co. Tuy nhin, khi bng chng v s bin i kh hu ngy cng r rt trn ton th gii, cc nghin cu dch t hc s ng vai tr cho nhng hiu bit mi v lnh vc ny. Bng 9.3. Chi ph do tc hi ca nhim v kim sot i vi ba tnh trng bnh Nht 8 (triu Yn, theo gi tr nm 1989)
Bnh do nhim Cht nhim chnh Chi ph kim sot nhim Chi ph do tc hi ca nhim Sc khe Bnh hen Yokhaichi Bnh Minamata Bnh ItaiItai
a

S sng

Ci thin mi trng

Tng 21.000

SO2, nhim khng kh Thy ngn, nhim nc Cadmium, nhim t v nc

14.800

21.000 (1.300)
a

125 600

7.670 740

4.270 880

690 890

12.630 2.510

. Da trn n b thc t cho cng ng. Con s ln hn l chi ph phi n b cho tt c nhng ngi b nh hng Hnh 9.1 m t phm vi tc ng sc khe v mt s cch tip cn dch t hc cn thit c th a ra nhng bng chng v nhng thay i sc khe mi xut hin. Hi ng lin quc gia v Bin i kh hu hi ng cc nh khoa hc do T chc kh hu th gii iu phi cng b nh k nhng nh gi v din bin ca tnh trng bin i kh hu ton cu v nhng nh hng ca n. Nhng ng gp ca dch t hc cho cc nghin cu v nh gi trong tng lai c lit k trong Hp 9.2.11 Cc nh dch t hc cn a ra mi lin quan gia kh hu v cc tnh trng sc khe mt cch chnh xc hn, vi nhng bng chng thuyt phc hn, v cn tin hnh nghin cu trn m hnh. S cn a ra nhng d bo v bin ng da

Dch t hc mi trng v ngh nghip 161

trn nhng m hnh kh hu khc nhau, v cn a ra mi lin quan gia kh hu v sc khe trong mi trng kinh t x hi th c th v cc chng trnh kim sot bnh truyn qua vect. Xu hng ca tnh trng suy dinh dng bao gm s phn b v bnh ng lng thc cng cn c nghin cu. Hnh 9.1 Bin i kh hu tc ng nh th no n sc khe 10

Phi nhim v liu lng

Khi nim chung
Cc nghin cu dch t v nh hng ca cc yu t mi trng thng c p dng vi mt s yu t c trng v c th nh lng c. Chnh v vy, nhng khi nim v phi nhim (exposure) v liu lng (dose) ng vai tr c bit quan trng trong dch t hc mi trng v bnh ngh nghip. Hp 9.2. Nghin cu dch t hc v tc ng sc khe do bin i kh hu
Nguy c sc khe cng ng qui m ln bao gm: Tnh trng bin i kh hu ton cu Tnh trng thoi ha t trng trt Tnh trng cn kit ngun thy sn Tnh trng thiu nc sch S bin mt ca mt s loi sinh vt v h sinh thi

Phi nhim c hai c trng: mc v khong thi gian phi nhim. Vi nhng yu t mi trng c th gy ra nh hng cp tnh nhiu hay t ngay sau khi phi nhim, mc phi nhim hin ti xc nh tc ng c xy ra hay khng (v d v dch do khi London dn n t vong do bnh tim v phi, hnh 9.2, l mt rong nhng v dch mi trng u tin trn th gii c ghi li chi tit).

162 Chng 9 Hnh 9.2: V dch khi London,12 thng 12 nm1952

Tuy nhin, nhiu yu t mi trng ch gy ra tc ng sau mt thi gian di phi nhim. iu ny chnh xc vi nhng ha cht c kh nng tch ly trong c th (nh cadmium) v nhng nguy c c tc dng tch ly (nh tia phng x hay ting n). Vi cc nguy c ny, mc phi nhim trong qu kh v khong thi gian phi nhim quan trng hn mc phi nhim hin ti. Tng lng phi nhim (hoc liu lng ngoi) cn c o lng. Ch s ny gn nh l tch s ca qung thi gian phi nhim v mc phi nhim. Trong cc nghin cu dch t, tt c cc c lng phi nhim v liu lng u o lng mi lin quan gia cc yu t mi trng v tnh trng sc khe cng ng. V d trong Hnh 1.1 yu t phi nhim c th hin ch l mc phi nhim (s iu thuc l ht trong ngy). Bng 5.2 l nh hng kt hp ca thi gian v mc phi nhim vi ting n dn n gim thnh lc. Liu lng bn ngoi cng c th o lng bng mt i lng kt hp, nh s bao thucnm i vi ht thuc hay s sinm (hay htnm) i vi phi nhim aming ti ni lm vic (xem Hnh 9.3). Trong mt s trng hp, c th s dng o lng gin tip, v d lu lng giao thng trong mt gi mt s v tr c th hoc lng xng tiu th hng nm l nhng ch s v phi nhim vi khng kh nhim. Nhng ch s ny c th c xem l nhng ch s p lc trong h thng th bc nguyn nhn (Chng 5). Mt s v d khc bao gm vic s dng thuc tr su trong mt khu vc hoc s tr sng trong cn nh sn bng loi sn c cha ch.13

Dch t hc mi trng v ngh nghip 163

Hnh 9.3: Mi lin h gia phi nhim aming (htnm) v nguy c tng i ca ung th phi14

Gim st sinh hc
Nu yu t mi trng trong nghin cu l ha cht, mc phi nhim v liu lng i khi c th c nh gi bng cch o nng trong dch c th hay m. Cch tip cn ny c gi l gim st sinh hc. Mu v nc tiu c s dng nhiu nht trong gim st sinh hc, tuy nhin vi mt s ha cht khc, dch hoc m c th khc c th c lu hn: tc thng c s dng trong cc nghin cu s phi nhim vi Methyl thu ngn t c; mng tay c s dng trong cc nghin cu phi nhim vi asen; phn xc nh phi nhim kim loi qua thc phm (c bit l ch v cadmium); sa m nh gi phi nhim vi ha cht tr su hu c clo v cc hydrocacbon clorinat khc nh polychloritenated biphenyl v dioxin; sinh thit m, xng, phi, gan v thn c th dng nghin cu bnh nhn nghi ng b ng c.

Phin gii s liu sinh hc

Phin gii s liu theo di sinh hc cn phi c s hiu bit chi tit v hot tnh v chuyn ha ca cht, gm cc s liu v thm thu, vn chuyn, tch ly v bi tit. Do s bi tit nhanh ca mt s ha cht, nn ch c nhng phi nhim gn nht mi c th o lng c. i khi ch mt m hay dch ca c th cho ta bit c phi nhim gn y v mt m hay dch khc cho bit liu tng th. V ha cht cn phi c thm thu ti c cc cht liu ch im sinh hc, liu lng o c trong trng hp ny c gi l liu thm thu hoc liu bn trong, ngc li vi liu bn ngoi c lng bng cc o lng mi trng. minh ha, Hnh 9.4 cho thy s tng nhanh lng cadmium trong mu trong nhng thng u sau khi bt u phi nhim, trong khi lng cadmium trong nc tiu khng c s thay i ng k no.15 Mt khc, sau mt thi gian di phi nhim th lng cadmium trong nc tiu l ch s rt tt m t liu tch ly. Mt trong nhng cu hi hc tp trong chng ny l yu cu ngi c tm thm nhng v d c th v vn ny.

164 Chng 9 Hnh 9.4. Lng Cadmium trong mu v nc tiu trong nm u tin ca phi nhim ngh nghip

o lng theo c th so vi theo nhm

Bin thin v thi gian
Cc o lng phi nhim trn c th bin thin theo thi gian. V th, tn s o lng v phng php s dng c lng phi nhim hay liu lng trong mt nghin cu dch t hc cn c nhng nhn nh thn trng. c lng c s dng phi c tnh gi tr (Chng 3) v cc o lng cn km theo cc qui trnh m bo cht lng xc nhn chnh xc ca o lng.

Bin thin v phi nhim

Gia cc c th, cng c s bin thin v mc phi nhim. Thm ch, nhng cng nhn lm vic cnh nhau trong mt nh my cng c mc phi nhim khc nhau do thi quen lm vic khc nhau hay do s phn b cc cht nhim cng khc nhau. V d, mt h thng my c th b d kh thi trong khi h thng my khc khng b. Nu mc phi nhim hay liu lng c o lng bng gim st sinh hc, mt ngun bin thin na l s khc bit v t l thm thu v bi tit ha cht gia nhng ngi khc nhau. Thm ch nhng ngi c cng liu phi nhim bn ngoi c th c liu phi nhim bn trong khc nhau.

Vn phn b
Mt cch trnh by s bin thin mang tnh c th l thng qua cc th phn b (Chng 4). S phn b liu lng ha cht theo c th thng lch v to nn s phn b chun do c logarit ha hn l phn b chun thng. L tng nht l hnh dng ca phn b liu lng cn phi kim nh tng nghin cu dch t hc c s dng cc o lng xc nh mc phi nhim. Nu s phn b c kt lun l phn b chun theo logarit th so snh nhm phi c tin hnh da trn gi tr trung bnh nhn thay cho gi tr trung bnh cng hay lch chun.

Dch t hc mi trng v ngh nghip 165

Mt cch khc l s dng t phn v hay bch phn v (Chng 4). V d, nh gi lng ch mt nhm tr c ng quan tm hay khng, gi tr trung bnh c th s t ngha hn l t l tr c liu trn mt ngng xc nh no . Nu lng ch trong mu 100 g/l l ngng ng quan tm v nh hng ca ch ln no, th thng tin v mc trung bnh ca nhm (nh 70 g/l) khng cho bit c bao nhiu tr c th b nh hng. S c nhiu ngha hn nu bit c 25% s tr c lng ch trong mu trn 100 g/l.

o lng tc ng
Mt s quan tm tng t lin quan n vic s dng gi tr trung bnh hoc bch phn v cng rt quan trng o lng tc ng. Ngy cng c nhiu mi quan tm n tc ng ca cc cc yu t ha hc trong mi trng n s pht trin tr tr v hnh vi ca tr. Trong mt s nghin cu, ngi ta o lng ch s thng minh (IQ Intelligence Quotient). S khc bit v IQ trung bnh gia cc nhm l rt t v cc nhm nh c bit quan tm bao gm nhng tr c IQ thp. Tuy nhin, s thay i nh trong gi tr IQ t 107 n 102 trong nghin cu kinh in ca Needleman v cng s16, trnh by trong bng 9.4, c th lm tng ln ng k t l tr c IQ di 70 (t 0.6% ln 2%), ngng xc nh thiu nng tr tu tr. Bng 9.4: Thang y v cc ch s ph trn thang Wechsler Intelligence i vi tr em c mc ch rng cao v thp16
WISCR Thang y IQ IQ thng qua li ni Thng tin T vng Con s S hc Gii thch ng dng IQ thng qua s thc hin Hon thin bc tranh Chun b bc tranh V phc tho Tp hp i tng M ho Tnh trng hn n Mc ch thp (<10 mg) (trung bnh) 106,6 103,9 10,5 11,0 10,6 10,4 11,0 10,8 108,7 12,2 11,3 11,0 10,9 11,0 10,6 Mc ch cao (>20 mg) (trung bnh) 102,1 99,3 9,4 10,0 9,3 10,1 10,2 10,3 104,9 11,3 10,8 10,3 10,6 10,9 10,1 Gi tr P (mt pha) 0,03 0,03 0,04 0,05 0,02 0,49 0,08 0,36 0,08 0,03 0,38 0,15 0,54 0,90 0,37

Liu qun th
Trong cc nghin cu dch t hc v ung th do cc yu t mi trng v ngh nghip, i khi liu qun th c s dng nh mt cch trnh by khc. l "liu bt buc" (dose commitment) hoc "liu qun th" (population dose), c tnh bng tng ca tng liu c nhn. Vi phng x, liu bt buc l 50 sievert (Sv), liu c

166 Chng 9 cho l s gy ra mt trng hp ung th dn n t vong. D liu bt buc c lin quan n 100 ngi vi liu c nhn l 0,5 Sv hoc 10.000 ngi vi liu c nhn l 5 mSv, th kt qu l c mt trng hp ung th dn n t vong. Tnh ton ny da trn gi thuyt c bn l khng c ngng ca liu c th m di ngng nguy c ung th bng khng v rng nguy ung th gia tng tuyn tnh vi liu phng x. Tuy nhin, bin thin liu trong nhm c th ln v nhng ngi phi nhim liu cao r rng l c nguy c ung th do phi nhim mi trng so vi nhng ngi khc.

Cc quan h liu hu qu
i vi nhiu yu t mi trng, cc nh hng thay i t ri lon tm l hoc sinh ha n bnh nng hoc t vong nh gii thch Chng 2. Thng thng, liu cng cao th hu qu cng nghim trng. Mi quan h gia liu v mc nghim trng ca tc ng c th c gi l mi quan h liu hu qu (hnh 9.5), m c th thit lp cho tng c nhn hay tng nhm (liu trung bnh m tc ng xy ra). mc cacbon mono-oxit (CO) thp(o bng carboxy haemoglobin trong mu), tc ng ch l au u nh, nhng khi liu tng ln, tc ng do CO nghim trng dn ln nh m t trong hnh v. Khng phi tt c u c phn ng ging nhau vi cng mt phi nhim mi trng, v th mi quan h liu hu qu i ca c th s khc vi mi quan h liu hu qu ca nhm. Hnh 9.5: Mi quan h liu hu qu

Mi quan h liu hu qu cung cp thng tin c gi tr i vi vic lp k hoch cc nghin cu dch t hc. Mt s hu qu ny c th d o lng hn mt s hu qu khc, v mt s khc c th c ngha c bit quan trng i vi y t cng cng. o lng nhng thay i trong mu hay nc tiu, hay cn gi l nhng ch s sinh hc, c th dng nghin cu nhng nh hng nh ban u cng nh mc phi nhim. Trong trng hp vi cadmium, lng protein khi lng phn t thp trong nc tiu l mt ch s sinh hc tt cho thy nh hng sm nht ln thn15. Mi quan h liu hu qu gip cho nh nghin cu la chn c nhng hu qu thch hp nghin cu.

Dch t hc mi trng v ngh nghip 167

Trong qu trnh xy dng cc tiu chun an ton, mi quan h liu hu qu cung cp cc thng tin c ch v nhng hu qu c th phng trnh c v v nhng hu qu c th s dng cho sng tuyn. Nu cc tiu chun an ton c xy dng mc m nhng hu qu t nghim trng c th phng trnh c, th cc hu qu nghim trng hn cng c kh nng c phng trnh, v chng xy ra nhng mc cao hn.

Cc mi quan h liu p ng
p ng c nh ngha trong dch t hc l t l nhm phi nhim xut hin mt hu qu c th. V l thuyt, m hnh mi quan h liu p ng c hnh ch S hoc ging nh phn b chun tch ly. Cc nghin cu dch t hc mi trng v ngh nghip cho thy nhiu v d v mi quan h liu p ng c m hnh phn b kiu ny. mc liu thp th hu ht khng ai b nh hng, cn liu cao hu ht mi ngi u b nh hng. iu ny phn nh s thay i trong tnh cm th ca mi c th i vi tc nhn nghin cu. Mi quan h liu p ng trong mt vi trng hp c th c lng nh mi lin quan ng thng, c bit l khi ch lin quan n mt khong hp nhng p ng thp. Cch tip cn ny thng dng nghin cu mi lin quan gia nguy c mc ung th v liu aming (Hnh 9.3) hoc lng thuc ht (Hnh 1.1). Mi quan h liu p ng c th thay i bi cc yu t khc nh tui. V d, gim thnh lc do ting n17, mt trong cc tc ng sc khe ph bin nht cc nh my, ni cho thy mi quan h liu p ng rt cht ch (Bng 5.2). C th xy dng mi quan h liu p ng i vi bt c yu t mi trng no c th o lng c. C th thy trong cc v d t cc nghin cu dch t hc chn thng c trnh by di y.

nh gi nguy c
nh gi nguy c
C nhiu nh ngha khc nhau v nh gi nguy c, nhng c th phin gii l mt loi nh gi nguy c sc khe ca mt chnh sch, hnh ng hay can thip c th. TCYTTG xy dng rt nhiu hng dn v phng php tin hnh nh gi nguy c, c bit l cc nguy c lin quan n an ton ha cht.

nh gi tc ng sc khe
nh gi tc ng sc khe c th c coi l mt loi nh gi nguy c tp trung vo mt qun th hay tnh trng phi nhim nht nh, trong khi nh gi nguy c c phm vi p dng rng hn, tr li cho cu hi nh: Loi ha cht ny c tim nng gy ra nhng nguy c sc khe no?. Ngy nay, nh gi tc ng sc khe c khuyn ngh rng ri nh l mt phng php nh gi gi tr tim nng ca nhng chnh sch v hnh ng can thip khc nhau.18

Qun l nguy c
T qun l nguy c c dng trong lp k hoch v trin khai nhng hnh ng nhm gim hoc loi b nguy c sc khe.

168 Chng 9

nh gi tc ng sc khe mi trng
Trong nhng nm gn y, ngy cng gia tng s quan tm n nh gi tc ng mi trng (phn tch d on) v kim tra mi trng (phn tch thc trng) trong cc d n pht trin cng nghip v nng nghip. Nhng qui trnh ny tr thnh qui nh php l rt nhiu nc. Thnh phn sc khe trong nh gi mi trng c gi l nh gi tc ng sc khe mi trng v l ng dng quan trng ca phn tch dch t hc trong sc khe mi trng. nh gi ny cng c dng d on cc vn sc khe tim tng trong vic s dng cc ha cht hoc cng ngh mi. C mt vi bc tin hnh nh gi nguy c mi trng: Xc nh nguy c sc khe mi trng no c th xut hin do cng ngh hoc d n nghin cu. C loi ha cht nguy him khng? Nu c, c th l nhng ha cht no? C loi nguy c sinh hc no khng? (xem Bng 9.1) Phn tch loi tc ng sc khe m mi nguy c c th gy ra (nh gi nguy c). Thng tin c th c thu thp t nhng r sot c h thng nhng y vn khoa hc (ging nh cch r sot Cochrane v iu tr i vi tng bnh c th, nh trnh by trong (Chng 3) i vi tng loi nguy c hoc tham kho cc nh gi nguy c quc t, nh sri Tiu chun Sc khe Mi trng hoc tp Ti liu nh gi Ha cht Quc t Tm tt do TCYTTG xut bn, Sri Chuyn kho do C quan nghin cu Ung th Quc t (IARC International Agency for Research on Cancer) xut bn v nu cn thit, b sung nhng thng tin ny bng cc nghin cu dch t hc nhng ngi phi nhim vi nguy c ang nghin cu. o lng hoc c lng mc phi nhim thc t nhng ngi c kh nng b nh hng, bao gm qun th chung hoc lc lng lao ng. nh gi phi nhim ngi cn tnh n gim st sinh hc v nhng thng tin v tin s phi nhim v nhng thay i theo thi gian thch hp. Tng hp s liu phi nhim tng nhm trong qun th phi nhim vi mi quan h liu tc ng v liu p ng i vi tng nguy c tnh ton nguy c sc khe tim tng trong qun th. Cc nghin cu dch t hc c th c s dng o lng trc tip nguy sc khe. Nguy c c th l kh nng tng nguy c tng i ca mt s tc ng sc khe nht nh hoc c th c tnh ton l s tng ln s trng hp ca mt loi bnh hoc triu chng c th (Hp 9.3) Hp 9.3: V d: nh gi tc ng sc khe
Mt v d v nh gi tc ng sc khe m c tc ng ng k n chnh sch sc khe mi 19 trng l nh gi tc ng do nhim khng kh lin quan n giao thng chu u. Da vo s liu theo di khng kh, c lng s ngi phi nhim v mi quan h liu p ng t cc nghin cu dch t hc, cc nh nghin cu tnh ton c s trng hp t vong tim tng do loi nhim khng kh ny (Bng 9.5). iu ng ngc nhin l s t vong do nhim ln hn rt nhiu s t vong do tai nn giao thng. Nghin cu ny l c s cho s ra i cho hng loi cc chnh sch kim sot khng kh nhim lin quan n giao thng chu u. Mt phn tch tng t cng c tin hnh New Zealand20 vi t s t vong do nhim khng kh v do tai nn giao thng (Bng 9.5). T s thp hn ny cho thy, nhn chung mc nhim khng kh thp hn chu u v nguy c tai nn giao thng th cao hn.

S pht trin gn y trong nh gi tc ng sc khe c s dng c lng gnh nng bnh tt. Cng c ny do TCYTTG xy dng trong sri ti liu Gnh nng bnh tt Mi trng.21 Ba bc chnh nh gi qun l nguy c bao gm:

Dch t hc mi trng v ngh nghip 169

Th nht, c lng nguy c sc khe cn nh gi trong mi lin quan vi nguy c chp nhn c xc nh hoc trong mi lin quan vi nguy c sc khe khc trong cng qun th. Gii hn phi nhim ti a, mc tiu y t cng cng hoc cc cng c chnh sch khc nhm bo v sc khe thng c p dng trong bc ny. Cu hi c bn l: c cn thit tin hnh bin php phng chng do nguy c sc khe c lng qu cao khng? Nu quyt nh l bin php phng chng l cn thit, bc tip theo l qun l nguy c nhm gim phi nhim. Vic ny c th bao gm thay i k thut nguy c loi b, lp t thit b qun l nhim hoc di ri d n c tim nng nguy him. Cui cng, qun l nguy c cng lin quan n gim st phi nhim v cc nguy c sc khe sau khi bin php kim sot la chn c trin khai. iu quan trng l phi m bo thc hin c s bo v mong mun v nhng bin php bo v khc c tin hnh khng chm tr. Trong giai on qun l nguy c, nh gi phi nhim v iu tra dch t hc ngi ng vai tr rt quan trng.

Bng 9.5. T l t vong do nhim khng kh (ngi trng thnh 30 tui) v tai nn giao thng(1996)
Nc Dn s (triu) T vong do tai nn giao thng (A) 8.919 963 597 502 T vong do nhim khng kh do giao thng (B) 17.629 2.411 1.762 399 T s (B/A)

Php o Thy s New Zealand

58,3 8,1 7,1 3,7

2,0 2,5 3,5 0,8

Dch t hc chn thng

Mt loi c bit ca phn tch dch t hc ng vai tr quan trng trong sc khe mi trng v ngh nghip l tai nn v dch t hc chn thng. Chn thng do tai nn giao thng ang tng ln tng ngy rt nhiu nc v l nguyn nhn t vong v tn tt ch yu nhng ngi tr tui v tr em. iu ny gy ra nhng tc ng rt ln i vi sc khe cng ng. Mi quan h liu p ng c th c to ra cho cc yu t chn thng vi cc phi nhim ngh nghip c th nh lng c. Mt v d l nguy c t vong ca nhng ngi i b b t m (Hnh 9.6).

Chn thng va chm giao thng

Mt v d kinh in v dch t hc chn thng ca cc va chm giao thng c m t bng mi quan h liu p ng gia tc t (liu) tn s chn thng (p ng) ca nhng li xe c eo v khng eo dy an ton (Hnh 9.7). y l nhng thng tin rt gi tr ra quyt nh cho vic tin hnh hai bin php phng chng khc nhau: gim tc v s dng dy an ton.

170 Chng 9

Chn thng ni lm vic

Cng tng t, chn thng nm trong s nhng vn sc khe quan trng nht do cc yu t ni lm vic gy ra. Cc yu t mi trng lin quan n nhng chn thng ny thng kh xc nh v o lng hn nhng yu t gy ra, v d, ng c ha cht. Tuy nhin, nhng tin b k thut v qun l trong nhng nm gn y gip gim ng k t sut chn thng hu ht cc nc thu nhp cao (xem C s d liu LABORSTA ca T chc Lao ng Quc t Geneva). Hnh 9.6. Nguy c t vong ca nhng ngi i b theo tc m ca t22

Hnh 9.7: Mi lin h gia tc li xe, s dng dy an ton v tn s chn thng ca li xe t trong cc v va chm23

Dch t hc mi trng v ngh nghip 171

Bo lc
Bo lc l mt vn y t cng cng khc thng xuyn c nu bt trong cc phn tch dch t hc trong nhng nm gn y.24 mt s nc c thu nhp cao, hnh ng git ngi l nguyn nhn t vong ch yu nhng nam gii tr tui, v thc trng ny thm ch cn ti t hn mt s nc c thu nhp thp v trung bnh. V d, c s d liu t vong cho thy Brazil, git ngi chim n 40% tng s trng hp t vong nam gii 15 24 tui. Sng thng c s dng trong cc v git ngi, v c xu hng ngy cng tng mt s nc.

T t
Mt nguyn nhn t vong quan trng khc l t t. Yu t mi trng dn n nh t t bao gm cc yu t kinh t v x hi24, nhng nhng v t t thnh cng cn ph thuc vo vic tip cn c nhng bin php t t, cng c th c coi l nhng yu t mi trng. Hnh 9.8 cho thy s tng ln ng ngi v s t t Ty Samoa sau khi cho php lu hnh loi thuc dit c cc c. Loi thuc ny sn c cng ng do thuc c s dng cho vic trng chui tt c cc lng. Khi cc bin php kim sot c trin khai, cc v t t gim hn. y l mt v d cho thy bng cch m n gin s v t t c th cho thy tc ng ca can thip phng chng. Hnh 9.8. S v t t Ty Samoa trong mi lin quan vi vic s dng thuc dit c.24

Cc im c bit ca dch t hc mi trng v ngh nghip

Dch t hc p dng trong lnh vc mi trng v ngh nghip xc nh: Nguyn nhn Lch s t nhin Tnh trng sc khe ca qun th Gi tr ca can thip v dch v y t

Mt im c bit ca dch t hc mi trng l c s a l ca n. nhim khng kh, nc v t thng lin quan n ngun c v tr a l xc nh. V vy, v bn phi nhim hay mc ca cc yu t mi trng c th l nhng cng c hu ch trong cc nghin cu dch t hc.

172 Chng 9 Cc nghin cu dch t hc mi trng thng yu cu c lng hoc lp m hnh xc nh phi nhim, do o lng phi nhim c th rt kh thc hin. Lp m hnh cht lng khng kh kt hp vi phn tch h thng thng tin a l (Geographical Information System GIS) c s dng trong nhiu nghin cu v tc ng sc khe do nhim khng kh. Mt v d v nh gi phi nhim l s ngy nng nit i-xt vt cc im ct khc nhau, v s ngi phi nhim cc khu vc khc nhau trong thnh ph da vo s liu iu tra dn s.

Thit lp tiu chun an ton

Mi quan h liu tc ng v liu p ng l c bit quan trng trong dch t hc mi trng v bnh ngh nghip v nhng quan h ny l c s cho vic thit lp cc tiu chun an ton. Mi quan h liu tc ng c th s dng quyt nh tc ng no l quan trng nht phng chng. Khi a ra mt quyt nh lin quan n mc p ng chp nhn c, mi quan h liu p ng a ra liu ln nht c th chp nhn c. TCYTTG xy dng mt sri hng dn v cht lng nc,25,26 cht lng khng kh27 v gii hn phi nhim ngh nghip ti a28 s dng phng php ny. p ng sau v tai nn ti c s nng lng nguyn t Chernobyl, hng dn xc nh thc phm nhim phng x cng c xy dng.29 Vi nhiu yu t mi trng, s liu hin c l cha a ra tiu chun mt cch chnh xc, v nhng d on c c s v kinh nghim thc t l nn tng cho nhng tiu chun an ton. Cn nhiu nghin cu dch t hc na cung cp thng tin v mi quan h liu p ng.

o lng phi nhim trong qu kh

Mt im c bit ca nhiu nghin cu xc nh nguyn nhn trong dch t hc ngh nghip l vic s dng h s cng ty hoc nghip on xc nh nhng c th c phi nhim trong qu kh vi mt loi nguy c hoc loi ngh nghip c th (xem Chng 3). Vi thng tin t h s, c th tin hnh c loi nghin cu thun tp hi cu. Bng phng php ny, ngi ta xc nh c mt s mi lin quan gia nguy c ngh nghip v tc ng sc khe.

Tc ng cng nhn khe mnh trong cc nghin cu ngh nghip

Cc nghin cu dch t hc ngh nghip thng bao gm nhng ngi c th cht khe mnh. V th, nhng cng nhn phi nhim c t l t vong thp hn so vi nhng ngi cng la tui cng ng. T l t vong thp hn c gi l tc ng cng nhn khe mnh, loi tc ng cn tnh n khi so snh t l t vong gia mt nhm cng nhn v cng ng.30 Thng thng t l ca nhm cng nhn khe mnh l khong 70 90% ca c cng ng. S khc bit ny sinh do s xut hin ca nhng ngi khng khe mnh hoc b tn tt trong qun th khng lm vic, thng l nhng nhm qun th c t l t vong cao hn.

Nhng thch thc khng ngng i vi nhng nh dch t hc

Chng sch ny nu ln nhng ng gp quan trng ca nhng nguy c mi trng v ngh nghip vo gnh nng bnh tt ton cu. Nghin cu dch t hc trong lnh vc ny gp phn cho nhng thng tin thit yu cho chnh sch y t v chin lc phng chng ang c p dng nhng nc c thu nhp cao. Ngy nay, nhng nh dch t

Dch t hc mi trng v ngh nghip 173

hc ang phi i mt vi nhng thch thc phi a ra nhng bng chng cho thy nhu cu v nhng chin lc tng t nhng nc c thu nhp thp v trung bnh. Nhng u tin v chnh sch y t i khi b s trng hp t vong nh hng, ngha l nhng trng hp t vong do mt loi nguy c sc khe no gy ra cn phi c chng minh trc khi nguy c din ra thc s. Do thc trng nhiu nguy c mi trng v ngh nghip lin quan n cc hot ng kinh t vi chi ph rt cao, bin php phng chng lnh vc ny thng gy nhiu tranh ci. Dch t hc c th a ra c s cho nhng chnh sch y t v mi trng da trn bng chng. Tranh ci xung quanh cc vn mi trng nh bin i kh hu lnh vc ch c mt s t bng chng dch t hc c tch ly nhng hnh ng nhm gim tc ng gy hi sc khe cn phi c tin hnh ngay. C rt nhiu c hi cho nhng nghin cu quan trng v ng quan tm trong lnh vc sc khe mi trng v ngh nghip, v lnh vc ny lun m cho nhng cch tip cn c tnh sng to v c o.

Cu hi
9.1 a. Trong bng 9.1, nhm no l d cm th vi ch nht? b. Ch s no l nhy cm nht ca phi nhim vi ch? 9.2 a. Liu ngoi tng cho kt qu no hnh 9.4? b. Ti sao liu aming thng tnh nh l "nhng nm nghin thuc l" hoc "nhng nm x ho. 9.3 Chn mt loi ha cht mi trng c hi v tin hnh tm kim trn Internet v cht liu gim st sinh hc (dch/m c th) m t phi nhim gn y v phi nhim tch ly lu di. 9.4 Bn l cn b y t cng cng trong mt thnh ph c va vi mt s nh my cng nghip ln. Cng nhn cc nh my ny c chm sc y t thng qua h thng bo him ng nht, ngha l tt c cc cng nhn hin lm vic v ngh hu u c chm sc y t ca cng bnh vin. Bc s ca bnh vin thng bo cho bn lo lng v mt s lng ln cc trng hp ung th phi cng nhn. Thit k nghin cu no c a ra iu tra mi quan h tim tng gia cc phi nhim ngh nghip v nguy c ung th phi. 9.5 Phn tch dch t hc nh th no v v dch do khi Lun n gy t vong do bnh tim v phi nm 1952 (Hnh 9.2) xc nh v dch thc t l do khi gy ra? 9.6 Tc ng cng nhn mnh khe c ngha l g v tc ng ny c th gy ra nhng sai lch g trong cc nghin cu dch t hc ngh nghip? 9.7 xut nhng nghin cu m GIS c th hiu qu nh gi phi nhim trong dch t hc mi trng. 9.8 M t thc trng nguy c chn thng trong cuc sng hng ngy ca bn t nhng bin php phng chng c th c xy dng t nhng nghin cu dch t hc.

174 Chng 9

Ti liu tham kho

1. Health and environment in sustainable development. Document WHO/EHG/97.8. Geneva, World Health Organization, 1997. 2. Smith KR, Corvalan CF, Kjellstrom T. How much ill health is attributable to environmental factors? Epidemiology 1999;10:573-84. Medline doi: 10.1097/00001648-199909000-00015 3. Pruess-Ustun A, Corvalan C. Preventing disease through healthy environments. Towards an estimate of the environmental burden of disease. Geneva, World Health Organization, 2006. 4. Canfield RL, Henderson CR, Cory-Slechta DA, Cox C, Jusko TA, Lanphear BP. Intellectual impairment in children with blood lead concentrations below 100 ug/l. N Engl J Med 2003;348:1517-26. Medline doi:10.1056/NEJ Moa022848 5. Meyer PA, Pivetz T, Dignam TA, Homa DM, Schoonover J, Brody D. Surveillance for elevated blood lead levels among children in the United States, 19972000. MMWR Surveill Summ 2003;52:1-21. Medline 6. Inorganic lead. (Environmental Health Criteria, No. 165).Geneva, World Health Organization, 1995. 7. Kjellstrm T, Lodh M, McMichael T, et al. Air and water pollution; burden and strategies for control. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al, eds. Disease control priorities in developing countries. New York, Oxford University Press, 2006:817-832. 8. Study Group for Global Environment and Economics. Office of Planning and Research, Pollution in JapanOur Tragic Experience. Tokyo, Japan Environment Agency, 1991. 9. McMichael AJ. Human frontiers, environments and disease: past patterns, uncertain futures. Cambridge, Cambridge University Press, 2001. 10. McMichael AJ, Campbell-Lendrum DH, Corvalan CF, Ebi KL, Githeko AK, Scheraga JD, et al. Climate change and human health, risks and responses. Geneva, World Health Organization, 2003. 11. Sunyer J, Grimault T. Global climate change, widening health inequalities and epidemics. Int J Epidemiol 2006;35:213-6. Medline doi:10.1093/ije/dyl025 12. United Kingdom Ministry of Health. Mortality and morbidity during the London fog of December 1952. London, Her Majestys Stationery Office, 1954. 13. Childrens health and the environment in North America. Geneva, World Health Organization, 2006. 14. Mcdonald JC, et al. Chrysolite Fibre Concentration and Lung Cancer Mortality: A Preliminary Report. In: Wagner, JC ed. Biological Effects Of Mineral Fibres. Vol. 2. (IARC Scientific Publications, No. 30), Lyons, International Agency for Research on Cancer, 1980:811817. 15. Cadmium: environmental aspects. (Environmental health criteria No. 134). Geneva, World Health Organization, 1992. 16. Needleman HL, Gunnoe C, Leviton A, Reed R, Peresie H, Maher C, Barrett P. Deficits in psychologic and classroom performance of children with elevated. 17. Noise. (Environmental Health Criteria, No. 12). Geneva, World Health Organization, 1980. 18. Dora C, Racioppi F. Including health in transport policy agendas: the role of health impact assessment analyses and procedures in the European experience. Bull World Health Organ 2003;81:399-403. Medline 19. Kunzli N, Kaiser R, Medina S, Studnicka M, Chanel O, Filliger P, et al. Public health impact of outdoor and traffic-related air pollution: a European assessment. Lancet 2000;356:795-801. Medline doi:10.1016/S0140-6736(00) 02653-2

Dch t hc mi trng v ngh nghip 175

20. Fisher G, Rolfe KA, Kjellstrom T, Woodward A, Hales S, Sturman AP, et al. Health effects due to motor vehicle pollution in New Zealand: Report to the Ministry of Transport. 2002:1-72. 21. Introduction and methods - Assessing the environmental burden of disease at national and loca levels. Geneva, World Health Organization, 2003. http://www.who.int/quantifying_ehimpacts/publications/en/. 22. Peden M, Sarfiled R, Sleet D, Mohan D, Hyder AA, Jarawan E, eds. World report on road traffic injury prevention. Geneva, World Health Organization, 2004. 23. Bohlin NI. A statistical analysis of 28 000 accident cases with emphasis on occupant restraint value. SAE transactions 1967;76:2981994. 24. Krug EG, Dahlber LL, Mercy JA, Zwi AB, Lozano R, eds. World report on violence and health. Geneva, World Health Organization, 2002. 25. Scoggins A, Kjellstrom T, Fisher G, Connor J, Gimson N. Spatial analysis of annual air pollution exposure and mortality. Sci Total Environ 2004;321:71-85. Medline doi:10.1016/j.scitotenv.2003.09.020 26. Guidelines for drinking-water quality. Vol. 1, Recommendations. Geneva, World Health Organization, 2004. 27. Air quality guidelines for Europe. (Regional Publications, European Series, No. 23) Copenhagen, World Health Organization Regional Office for Europe, 1987. 28. Recommended health-based limits in occupational exposure to heavy metals: report of a WHO Study Group. WHO Tech Rep Series 1980;647. 29. Derived intervention levels for radionuclides in food. Guidelines for application after widespread radioactive contamination. Geneva, World Health Organization, 1988. 30. McMichael AJ. Standardized mortality ratios and the healthy worker effect: scratching beneath the surface. J Occup Med http://dx.doi.org/10.1097/00043764-197603000-00009

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Chng 10

Dch t hc, chnh sch y t v lp k hoch y t

Thng ip chnh
Dch t hc cung cp thng tin cho vic pht trin, thc thi v nh gi chnh sch y t v lp k hoch. Vic tham gia ca nh dch t hc em lai li ch cho cc vn lin quan n chnh sch y t. Cc k thut dng trong nh gi cc can thip ca chnh sch y t cn c iu chnh. Lp k hoch y t l mt chu trnh kn m tt nht l bao hm c vic nh gi lin tc hiu qu.

Gii thiu
Gi tr y ca nghin cu dch t hc ch c nhn ra khi n c s dng trong xy dng chnh sch y t v cc hot ng k tip nh xy dng k hoch v trin khai cc chng trnh phng chng dch bnh hay chn thng. Nh chng ta thy, c th c mt s nh tr/chm tr gia vic thu nhn c s hiu bit v vic s dng n ca cc nh ra chnh sch v lp k hoch y t. Trong chng ny chung ta m t cch thc m kin thc dch t hc cung cp cho vic hnh thnh chnh sch v lp k hoch. Nguyn l vn tng t thng qua mt lot cc hot ng t trin khai chng trnh cho n nh gi dch v sc kho. Nhng trc ht, chng ta xem xt nhng nh ngha sau:

Chnh sch y t
Chnh sch y t cung cp mt khung chng trnh cho cc hnh ng tng cng sc kho bao gm cc yu t quyt nh sc kho nh cc yu t x hi, kinh t v mi trng. Chnh sch y t c th c xem nh l mt tp hp ca cc quyt nh v cc mc ch chin lc cho khu vc y t v cch thc nhm t c cc mc ch chin lc ny. Chnh sch c th hin qua cc chun mc, thc hnh, qui nh v lut nh tc ng ln sc kho qun th. Cc ni dung ny cng vi nhau to nn hnh hi, nh hng v tnh nht qun i vi cc quyt sch theo thi gian.

Lp k hoch y t
Lp k hoch dch v y t l mt qu trnh xc nh cc mc tiu ch cht v la chn cc cch thc thc hin khc nhau nhm t c mc tiu ra. Trong khi qu trnh m ch mt tp hp cc hnh ng hp l, thc t cng tc lp k hoch thng khng d on c. (Xem hp 10.5).

178 Chng 10

nh gi
nh gi l mt qui trnh mt cch khch quan v h thng nht c th xc nh s ph hp, tnh hiu qu, hiu sut v tc ng ca cc hot ng trong mi tng quan vi mc ch c t ra. Vic nh gi mt chng trnh can thip c th l mt cng vic cao cp; kh khn v gy nhiu tranh ci hn nhiu, xc nh v so snh s th hin ca h thng y t. 1 Cc nh dch t hc lm vic vi cc chuyn gia khc nhm thng bo cho cng ng v cc nh hoch nh chnh sch ca cc cng ng ny lm sao cc la chn chnh sch c thc hin vi s hiu bit ton b v kt qu v chi ph.

Chnh sch y t
Chnh sch cng cng l tng hp cc quyt nh nh hnh x hi. N cung cp mt khun kh cho s pht trin, nh sn xut cng nghip v nng nghip, s qun l ca nghip on, cc dch v y t. Chnh sch vch ra mt lot cc cch/kh nng khc nhau trong cc t chc v c nhn c th la chn cho ring mnh v v vy n tc ng mt cch trc tip ln mi trng v mu hnh ca cuc sng. Chnh sch cng cng l yu t quyt nh chnh i vi sc kho ca ngi dn. Chnh sch y t, theo ngha hp, lin quan mt cch c th n cc kha cnh ca chm sc y t v vic t chc cc dch v y t. Tuy nhin, sc khe chu s tc ng ca hng lot quyt nh chnh sch, khng ch trong lnh vc y hc v y t . Mt chnh sch y t ng n phi a ra c khun kh cho cc hot ng tng cng sc kho bao gm cc yu t quyt nh ln sc kho nh x hi, kinh t v mi trng.

nh hng ca dch t hc
Nu nh dch t hc hng ti lnh vc d phng, v kim sot cc bnh th kt qu ca cc kt qu nghin cu dch t hc phi tc ng ln chnh sch cng cng. n nay, dch t hc vn cha lm trn bn phn ca n trn phng din ny, v ch mt s t lnh vc, trong cc nghin cu dch t c p dng y . Tuy nhin, tm quan trng ca dch t hc i vi vic ra chnh sch ngy cng c tha nhn (xem Hp 10.1). Quan im ca cng ng hay d lun ng vai tr trung gian cho cc nh hng ca dch t hc. Cc nh hoch nh chnh sch trong nhiu nc thng p ng vi d lun hn l nh hng d lun. S gia tng mi quan tm ca truyn thng i chng i vi cc nghin cu dch t hc lm gia tng s hiu bit ca cng ng v cc vn sc kho. Dch t hc thng l mt yu t quan trng nh hng n chnh sch cng cng, nhng t khi n l mt yu t nh hng duy nht. Kh khn chnh trong vic ng dng dch t hc vo trong chnh sch cng cng l vic cn c s phn quyt v nguyn nhn bnh v v vic quyt nh nhng iu cn phi lm khi cha c y bng chng. Mt s nh dch t tin rng vai tr ca h ch hn ch trong cc nghin cu dch t, mt s khc cho l h phi tham gia trc tip vo vic ng dng kt qu cho hoch nh chnh sch cng cng, s khc bit ny phn nh s thch mang tnh c nhn, x hi v vn ha. Nu nh mt vn sc khe l vn gy tranh lun phn ln cc vn sc kho l nh vy th cc nh dch t hc tham gia vo trong lnh vc chnh sch cng cng c th b ph phn v tnh thin lch hoc phin din ca mnh. Tuy nhin, cng c mt yu t khc l cc gi chnh sch ca nghin cu dch t c kh nng b lng qun.

Dch t hc, chnh sch y t v lp k hoch y t 179

Hp 10.1. Cc yu t thnh cng trong vic hnh thnh chnh sch2

thnh cng trong vic hnh thnh chnh sch cn c: nhim v chnh tr cp cao trong vic xy dng khung chnh sch cp quc gia; mt nhm cc nh khoa hc ch cht c nhim v nh gi nhu cu sc kho, bin minh cho hnh ng v xy dng chnh sch v k hoch cp quc gia; hp tc quc t nhm cung cp s h tr chnh tr v k thut; ly kin rng ri trong khu son tho, r sot v son tho li cho n khi chnh sch c xc nhn; nhn thc c rng qu trnh ly kin cng quan trng nh son tho ni dung nhn c s h tr v quyn s hu; pht trin v trin khai chin lc truyn thng nht qun cho tt c cc giai on ca qu trnh; lm r nh hng ca mt nhm cc mc tiu mang tnh nh hng kt qu.

Khi ng dng dch t hc trong chnh sch cng ng ca mt nc ny, cn a ra nhng quyt nh kh khn da trn kt qu ca cc nghin cu c tin hnh cc nc khc. Nhiu khi khng th v c th khng cn thit tin hnh trin khai li phn ln cc nghin cu c trin khai nc khc. Tuy nhin, cn phi c mt vi bng chng ca a phng, nc s ti trc khi c quyt nh thay i chnh sch hoc c s can thip tn km. Cc bng chng mang tnh a phng cung cp thng s cho cc kt qu d kin m c th to ng lc cho cc hnh ng d phng.

To khung chnh sch

Trong vic to khung chnh sch, vic s dng cc s liu so snh lin quan n t vong v tn tt s gip: cn chnh tc ng ca cc hu qu sc kho khng gy t vong n qun th; thng bo cc trao i v xc nh u tin cho phn b v lp k hoch dch v chm sc y t; v nghin cu v pht trin h thng y t.3 S dng cc ch s tng hp s d dng cho c vic lp k hoch v nh gi chng trnh. Ch s o lng s nm sng iu chnh theo mc tn tt (DALY) thng c s dng v n tnh m n c t vong v tnh trng mi mc bnh. S thay i mt hay c hai thng s theo cc o lng chun c th c s dng theo di s thay i theo thi gian (Chng 2). Hu ht cc chnh sch u tc ng ln sc kho. Cc quyt nh chnh sch mt lot cc t chc khc nhau k c cc c quan chnh ph v phi chnh ph u c tc ng ng k ln sc kho. Mi quan tm v sc kho v bnh ng l cn thit trong tt c cc lnh vc ca chnh sch cng cng, chng hn nh: cc chnh sch nng nghip nh hng ln s sn c, gi c v cht lng ca tht v cc sn phm b sa; cc chnh sch v qung co v ti chnh nh hng ln gi v s sn c ca thuc l hay cc thc phm c li cho sc kho nh hoa qu; v cc chnh sch lin quan n giao thng vn ti nh hng ln qui m ca nhim khng kh th v nguy c ti nn giao thng.

Cch tip cn chnh sch x hi rng ny i lp vi chnh sch y t, trong chnh sch y t thng ch yu v trc tip hng ti cc c nhn hay nhm ngi m t n cc hnh ng cp qun th.

180 Chng 10 Hin chng Ottawa nm 1985 i vi vic tng cng v nng cao sc khe cho thy r rng, sc khe chu nh hng bi mt lot cc quyt nh v chnh sch.4 Hin chng ny lm r rng, chnh sch y t khng ch n gin l trch nhim ca cc c s y t. Hin chng Bangkok v tng cng sc kho trong th gii ton cu ho (2005) a ra nhn nh rng tng cng sc kho ph thuc vo vic trao quyn cho tt c cc lnh vc gii quyt tc ng ton cu ln sc kho.5 (Hp 10.2) Mt mc ch ca chnh sch cng c li cho sc kho l tng cng sc kho (lm cho ngi dn tng cng vic kim sot v ci thin sc kho ca chnh mnh). Tng c nhn ng mt vai tr nhm t c mc ch ca chnh sch cng c li cho sc kho. Hp 10.2. Hin chng Bangkok i vi tng cng sc kho5
Hin chng Bangkok ku gi cc ban ngnh v cc lnh vc nhm: vn ng cho sc kho da trn nhn quyn v tinh thn on kt u t vo cc chnh sch bn vng, hnh ng v h tng c s nhm gii quyt cc yu t quyt nh sc kho xy dng nng lc cho pht trin, t cch lnh o v thc hnh tng cng sc kho, nghin cu v chuyn giao kin thc v sc kho ban hnh cc qui nh v lut nh nhm bo v mc cao nht t cc yu t c hi v to c hi bnh ng trong sc kho v thoi mi cho tt c mi ngi xy dng mt lin minh vi cc t chc quc t, phi chnh ph, chnh ph, t nhn v cng cng v cc hi on dn s nhm to nn cc hnh ng bn vng. lm c iu ny, c 4 s cam kt c xc nh thc hin cngtc tng cng sc kho. C chng trnh ngh s cho vic pht trin t trung ng cho n ton cu Trch nhim chnh cho rtt c chnh ph Cc im u tin mu cht ca cc cng ng v cc hi oan x hi Tiu ch i hi cho vic thc hnh tt s phi kt hp

Chnh sch y t trong thc t

Khung thi gian ca vic ng dng cc nghin cu dch t phc v hoch nh chnh sch thng thay i, c bit l i vi nhng bnh mn tnh thi gian c th tnh bng thp k hn l theo nm. Hp 10.3 cho thy cc pht hin ca cc nghin cu v bnh ng mch vnh v cc quyt nh v chnh sch tng ng M. V d ny ch ra cc bc hnh thnh chnh sch song song qu trnh lp k hoch chm sc y t s c trnh by sau trong chng ny. Hp 10.3. Tin trnh ca vic hnh thnh chnh sch quc gia lin quan n bnh mch vnh.
Ngay t u nhng nm 1950, ngha y t cng cng ca bnh ng mch vnh c cng nhn mc d c rt t hiu bit v cc yu t nguy c. Tuy nhin, c nghi ng v mi lin quan gia Cholesterol huyt thanh v bnh ng mch vnh tim da trn c s cc th nghim trn ng vt cc chuyn gia bnh hc cho thy Cholesterol l thnh phn chnh nm trong cc tn thng s va ng mch ngi. Cc nghin cu quc t trong nhng nm 1950 bt u tm hiu vai tr ca cht bo trong ch n, v nhiu nghin cu thun tp ln c tin hnh. Vo nhng nm cui ca thp k 1950, bng chng t nhng nghin cu quan st ngy cng cho thy tm quan trng ca lng Cholesterol huyt thanh tng, huyt p cao v ht thuc l l cc yu t nguy c chnh ca bnh mch vnh.

Dch t hc, chnh sch y t v lp k hoch y t 181

Nhng nghin cu dch t hc quan st c b sung trong nhng nm 1960 bng giai on u tin ca th nghim lm sng nhm kim nh tc ng ca ch n king m n t l mc bnh mch vnh. Nhiu trong s cc th nghim lm sng ny c thiu st v mt s cho kt qu khng thuyt phc, mc d xu hng l thng nht. iu c sm nhn ra rng cc th nghim xc nh cc yu t lin quan n ch n v bnh mch vnh l khng thc t v ngi ta li hng ch n tc ng ca thuc gim Cholesterol. Trn phng din chnh sch, nhiu cng b chnh thc c a ra, bt u vo nm 1960 vi bn cng b u tin do Hi tim ca M. Hi ngh quc gia v thng nht s pht trin vo nm 1985 M nhn mnh vic tng cng phng nga bnh mch vnh, c th l qua cc c gng h thp mc cholesterol c hai nhm l nhng ngi c nguy c cao v trong qun th chung. Chng trnh ny bao gm chin dch gio dc ton quc v mc cholesterol cao, chng trnh chun ha cc phng th nghim, cc c gng lin tc nhm h thp mc cholesterol thng qua cc chin lc hng ti c qun th v nhm c nguy c cao. Nm 2003, Trung tm Kim sot v Phng chng bnh (CDC) pht trin mt k hoch hnh ng y t cng cng quc gia ton din nng cao sc khe tim mch. Mc tiu ca k hoch ny l tp hp cc t chc y t cng cng, cc i tc quan tm v cng ng, y mnh vic ohng chng bnh tim mch v t qu trong vng hai thp k ti. Phi mt hn 50 nm cc chnh sch phng chng v kim sot ton din bnh tim mch v t qu ra i M. Tuy nhin, s nhn mnh ca cc chnh sch cng cng i vi bnh tim mch vn hng ti tc ng vo hnh vi c nhn, c nhm cc chuyn gia y t cng nh cng ng.

phn ln cc quc gia, ngi ta t dnh s ch cho cc chng trnh can thip da trn cng ng mang tnh di hn i vi bnh tim v thm tr cn t hn na i vi vic h tr cho vic thay i cc thi quen n ung, vn ng th lc v gim ht thuc l cp qun th. Tuy nhin bnh mch vnh l bnh khng truyn nhim u tin nhn c nhiu s quan tm ca c cc nh nghin cu v cc nh hoch nh chnh sch. C th ni rng, hnh ng a ra nhm kim sot cc bnh khng truyn nhim chnh s c din ra nhanh hn da trn c s kinh nghim thc tin thu c, v d nh i vi vic kim sot s dng thuc l. (Hp 10.4) Hp 10.4. Tin trnh ca vic hnh thnh chnh sch ton cu. Hip nh khung v kim sot thuc l
S tin trin mang tnh ton cu c din ra vi cc n lc trong vic kim sot thuc l, mt yu t c coi l nguy c chnh ca bnh khng truyn nhim c th phng c v l mt v d tt v cch thc m cc quc gia s dng cc hiu bit dch t hc mt cch tng th thay i chnh sch. Cc bng chng dch t hc v tc hi ca thuc l cui cng cng dn n vic hnh thnh nn hip nh khung v kim sot thuc l vo thng hai nm 2006, mt hip c u tin v sc kho c cc quc gia thnh vin ca T chc Y t th gii chp thun. Cho n cui nm 2006, c 142 quc gia thng qua hip nh ny. Phng nga cp 0 (primodial prevention) c hiu qu tc l ngn cm cc hot ng khuyn mi thuc l v ngn cn mi ngi ht thuc cn c cc qui nh cht ch cp nh nc v cc chnh sch ti chnh cho vic kim sot thuc l.6 Hip nh khung c pht trin nhm p ng vi vic ton co ho ca dch thuc l. Dch thuc l c khuych i bi mt lot cc yu t khng c bin gii, bao gm c yu t t do thng mi, u t nc ngoi trc tip, tip th ton cu, qung co thuc l xuyn quc gia, khuyn mi v ti tr, v tro lu bun lu quc t v lm gi thuc l. Hip nh ny tiu biu cho mt s thay i ln qua vic xy dng mt chin lc mang tnh nguyn tc cp n cc cht gy nghin. i li vi hip c kim sot ma tu trc y, hip nh ny cp n vic gim nhu cu cng nh gim cung cp. Vic trin khai thnh cng Hip nh khung s cu c hng triu mng sng.

182 Chng 10 i vi cc bnh truyn nhim, cc hot ng YTCC thng din ra nhanh hn bi cc v dch bnh truyn nhim thng c nhn nhn nh l mi e do khn cp cp quc gia v cng l mi e do i vi kinh t. Bnh SARS, tuy ch tc ng ln 8.000 ngi v l nguyn nhn gy nn 1.300 t vong, c c tnh gy nn mt tn ph khong 30 140 t la M. Vic i li v cc hot ng thng mi b nh hng nghim trng do mi lo s nhim bnh v cc chng trnh d phng tn km c trin khai nhiu quc gia. Cc ngun lc khc nhau c u t mt cch nhanh chng vo vic pht trin cc c ch cnh bo v p ng, tng t cc Qui nh v y t quc t (xem Hp 7.2) c iu chnh tng ng vi tnh hnh. Cc nh dch t hc lm vic trong mt mi trng i tc rng ng vai tr quan trng trong vic kim sot bnh.

Xy dng k hoch v nh gi chm sc sc kho

Trong phn ny, chng ti s minh ho qui trnh lp k hoch v nh gi can thip sc kho i vi mt s bnh c th. Mt qui trnh tng t s c p dng vo cc can thip rng hn nh xy dng chng trnh chm sc sc kho cho ngi cao tui cp quc gia hay mt cch tip cn mi trong cung cp cc dch v chm sc sc kho ban u cc khu vc nng thn. S dng mt cch h thng cc nguyn l v phng php dch t hc trong vic lp k hoch v nh gi cc dch v y t l mt kha cnh quan trng ca dich t hc hin i. nh gi gi tr ca nhng bin php iu tr c th c coi l mt bc khi u nhm nh gi nng lc tng qut ca cc dch v y t. Mc ch cui cng mc d c l khng thc t l xy dng mt qui trnh r rng cho vic la chn u tin v phn b cc ngun lc hn hp dnh cho y t. Bi ngun lc dnh cho chm sc y t thng l hn ch tt c cc nc, cho nn cn la chn cc chin lc ci thin sc kho khc nhau (xem Chng 6). cc nc ngho, chi ph dnh cho cc dch v y t cng cng ch l mt vi la trn u ngi. Kt qu l c nhn v gia nh c kh nng chi tr mt phn ln cc chi ph dch v y t, y c gi l chi tr trc tip (outofpocket expenses). mt thi cc khc, M, chi ph chm sc y t trn u ngi hng nm vo khong 5.600 la.

Chu trnh lp k hoch

Hnh 10.1 ch ra cc bc trong qu trnh lp k hoch chm sc y t v cung cp mt s hu ch nhm bo m rng cc thng tin do nhng ngi xy dng chnh sch yu cu c xc nh. Qu trnh lp k hoch l qu trnh c tnh chu k v lp li vi cc bc sau: o lng v nh gi gnh nng bnh Xc nh cc nguyn nhn ca bnh o lng tnh hiu qu ca cc can thip cng ng khc nhau nh gi hiu sut (efficiency) trn phng din ngun lc s dng Trin khai/tin hnh can thip Theo di cc hot ng v nh gi tin

Dch t hc, chnh sch y t v lp k hoch y t 183

Hnh 10.1. Chu trnh lp k hoch y t

Thng thng ch mt phn ca thng tin cn cho vic ra quyt nh l sn c v cc thng tin ny lun lun cn c nh gi cn thn. Nu ngun thng tin khng th cn phi thu thp s liu mi bo m rng vic la chn chnh sch c thc hin mt cch hp l. Nhm a ra quyt nh sng sut, r rng trong vic a ra quyt nh, tt c cc gi thuyt phi c nu mt cch r rng. Cch ny c th p dng cho vn chnh sch y t khc. Tuy vy, cn thn trng trong vic p dng (Hp 10.5).7 Dch t hc tham gia vo tt c cc giai on ca chu trnh lp k hoch Bn cht chu k ca qu trnh lp k hoch cho thy tm quan trng ca vic theo di v nh gi xc nh xem cc can thip c c cc tc ng nh mong mun hay khng. Qu trnh mang tnh lp i lp li v mi mt chu k ca s can thip thng ch c tc ng nh ln gnh nng ca bnh v s can thip cn phi c lp li. Mt v d n gin ca chu trnh lp k hoch l khung lp k hoch theo bc (Hnh 10.2) c T chc y t th gii xy dng nhm lp k hoch i ph vi bnh khng truyn nhim cho thy s ph hp i vi nhiu vn chnh sch ln khc.8

nh gi gnh nng bnh tt

o lng tnh trng sc khe tng th ca cng ng l bc u tin trong qu trnh lp k hoch. nhng ni khng c thng tin, nhng thng tin v tn sut ca nhng yu t nguy c chnh i vi bnh nht l i vi nhng bnh c t yu t nguy c chnh, v cc yu t nguy c thay i tc ng d bo bnh mn tnh c th khi ng cho vic xy dng k hoch i ph vi cc bnh ny. (cc thng tin ny c th thu thp thng qua h thng gim st s dng cch cp theo bc STEPS). (Hp 10.6)

184 Chng 10

Hp 10.5. iu cn ch : thc t ca vic lp k hoch Hu ht nhng m hnh lp k hoch, bao gm c khung bc thang, u s dng phng php trnh t v cn bn. Trong khi khung bc thang c u im ca vic a ra nhng trnh t v tp hp c nhiu lnh vc xung quanh mt tp hp nhng hnh ng, phng php ny khng t ng gii quyt c nhng kh khn gp phi khi lp k hoch cho cc chng trnh phng v kim sot bnh. Thc t l cc hnh ng y t cng cng l tng ln, c tnh cht c hi, v thng xuyn xy ra tnh trng nghch o hay i chiu. u tin i vi cc chng trnh y t khc nhau mt phn ph thuc vo bi cnh chnh tr. iu quan trng l phi xc nh, v d on mt cch tt nht, bi cnh chnh tr tm quc qua hoc a phng chuyn thnh nhng c hi nng cao sc khe. u tin ca nhng nh lnh o c th hnh thnh theo kinh nghim c nhn ca h. C rt nhiu v d vi lnh o, l ngi tng tri qua mt cn bnh no , la chn bnh thnh u tin quc gia hnh ng. Nhng nh lnh o ny c th l nhng lin minh quanh trng cho s thay i.

T vong v mc bnh
Mt cch l tng l qu trnh o lng gnh nng ca bnh phi bao hm cc ch s c th nh gi ton din tc ng ca bnh tt ln x hi. Nhng s liu t vong ch phn nh mt kha cnh ca sc khe, v c gi tr gii hn trong mi lin quan n cc bnh him khi t vong. S o tnh trng mc bnh phn nh mt kha cnh quan trng khc ca gnh nng bnh. Cng cn tin hnh o lng hu qu ca bnh tc l s khim khuyt (impairment), gim kh nng (disability) v tn ph (handicap) (Xem chng 2). Gnh nng ca bnh, trn c s s trng hp hay tc ng sc kho cp qun th do yu t c th gy nn, c gi l tc ng y t cng cng ca n. nh gi tc ng sc kho tr thnh cng c quan trng trong vic xy dng chnh sch y t u tin c s dng trong sc kho mi trng v gi y c s dng trong tt c lnh vc chnh sch. Hp 10.6. o lng gnh nng ca cc yu t nguy c i vi bnh mn tnh
T chc y t th gii (TCYTTG) pht trin mt cng c nhm gip cc nc nh gi t hp yu t nguy c cch tip cn ny c gi l tip cn theo bc p dng trong gim st (STEPS). Cch tip cn theo bc ca TCYTTG tp trung vo vic nng cao nng lc ca cc nc thu nhp thp v trung bnh trong vic thu thp mt phn cc s liu v nguy c vi cht lng cao. Bc 1 thu thp cc thng tin lin quan n vic s dng thuc l, ru, ch n v hot ng th lc thng qua b cu hi nh lng; Bc 2 thu thp s liu lin quan n huyt p, chiu cao v cn nng thng qua cc o lng th cht; Bc 3 thu thp cc mu mu o lng lng m v ng trong mu. Mc d phn ln cc nc u c ngun lc cho vic tin hnh cc bc 1 v 2, bc 3 thng c mc chi ph cao v khng ph hp trong tt c bi cnh. Tip cn theo bc c thit k nhm ph hp vi nhu cu thc t ti a phng v ng thi xut cc cu phn m rng khc (v d vi cc vn lin quan n sc kho rng ming, t qu) trong lc khuyn khch mi ngi thu thp cc s liu c chun ho nhm mc ch so snh gia v trong cc nc theo thi gian. Cun sch gii thiu v cch s dng cp theo bc c th ly c xung t a ch: http://www.who.int/chp/steps

Dch t hc, chnh sch y t v lp k hoch y t 185

Hnh 10.2. Khung bc thang trong phng bnh8

Lp k hoch bc 1: Xc nh nhu cu qun th v vn ng hnh ng Lp k hoch bc 2: Xy dng v thng qua chnh sch Lp k hoch bc 3: Xc nh cc bc thc hin chnh sch

Cc bc thc hin chnh sch Bc trin khai 1. C bn Bc trin khai 2. M rng Bc trin khai 3. T i u

Can thip c th Cp quc gia Cp di quc gia Can thip c tnh kh thi khi trin khai vi nhng ngun lc sn c trong ngn hn Can thip c th trin khai c khi ngun lc c tng thm hoc iu chnh trong trung hn Can thip da trn bng chng nm ngoi kh nng ca ngun lc sn c

Can thip cng ng

Cc o lng qun th tng hp

Cc o lng tng hp gnh nng bnh v chn thng cn phi xc thc v n gin cho vic phin gii (xem Chng 2). C nhiu gi thuyt khc nhau lin quan n vic s dng cc ch s ny v chnh v vy cn thn trng khi phin gii chng. Tuy nhin cc ch s ny cung cp cc la chn c ch cho vic ra chnh sch v lp k hoch y t c r rng hn.9

nh gi nhanh
nh gi nhanh l mt lnh vc ca nghin cu dch t hc s dng nhiu phng php nhm nh gi thc trng cc vn sc kho v nh gi cc chng trnh y t cc nc c thu nhp thp v trung bnh lm sao c c hiu sut cao nht. nh gi nhanh bao gm cc phng php s dng trong chn mu v iu tra cc khu vc nh, h thng gim st, sng lc v nh gi nguy c c th, cc ch s cng ng lin quan n cc yu t nguy c v tnh trng sc kho, cng nh cc nghin cu bnhchng s dng trong nh gi.10

Tm hiu nguyn nhn

Mt khi gnh nng ca bnh trong mt cng ng c o lng, bc th hai l xc nh nhng nguyn nhn gy bnh chnh m c th phng c; trn c s chng ta s xy dng cc chin lc can thip. iu ny ti khng nh vi chng ta rng cc nguyn nhn t vong chnh dng nh c cng cc yu t nguy c trong phn ln x hi.11 Chnh v vy m nhng nghin cu v cn nguyn c th khng nht thit phi trin khai trn tng x hi ring bit. Can thip phi phng nga c bnh nh l trng tm ban u c xc nh, nhng iu ny khng phi lc no cng thc hin c. Vai tr ca dch t hc trong vic xc nh cc yu t cn nguyn c bn lun trong chng 5.

186 Chng 10

o lng hiu qu can thip

i vi bc th ba, chng ta cn cc thng tin nhm ch dn vic a ra quyt nh v phn b ngun lc v mi lin quan gia cc chng trnh can thip sc kho v thay i tnh trng sc kho. Cc mi quan h trn c th c c tnh ho trn c hai phng din l nh lng v nh tnh. C cu ca t chc cung cp dch v y t, v qu trnh chm sc y t, c ngha l nhng hot ng ca nhn vin y t, c th c m t. Tuy nhin, cc cch cp nh tnh, mc d quan trng, nhng ch cung cp nhng thng tin gii hn lin quan n vic vn hnh ca cc dch v y t. Cc s liu nh lng ng thi cng cn phi phn tch hon thin thng tin. Chng ta c th o lng hiu qu thng qua xc nh t l phn trm gim xung ca tnh trng mc bnh, hoc t vong do/hay l kt qu ca can thip c th. (Hp 10.7) Hp 10.7. Cc yu t xc nh tnh hiu qu ca cc chng trnh can thip
Tnh hiu qu ca chng trnh can thip trong cng ng c xc nh bi nhiu yu t. Tnh hiu qu ca chng trnh can thip trong bi cnh nghin cu. Nu nh chng trnh can thip khng c hiu qu trong iu kin l tng th n kh c th mang li hiu qu khi trin khai ti cng ng. Vic lu tm mt cch st sao ti chn on, qun l di hn v theo di thng xy ra trong cc nghin cu th nghim lm sng c kim sot. Nhng th nghim lm sng nh th ny cho thy rng vic iu tr cao huyt p th nh lm gim t l t vong hay t qu khng gy t vong vo khong 40%. Tuy nhin do cc vn lin quan n vic tun th iu tr v vic la chn bnh nhn phng thc iu tr bng thuc gim huyt p (antihypertensive) li km hiu qu trong cng ng. Kh nng sng lc v chn on bnh cng tc ng n kt qu (xem Chng 6). Can thip phi c tt c nhng ngi m can thip c th em li li ch; iu ny c ngha l can thip phi sn c, chi tr c v chp nhn c i vi cng ng.

nh gi hiu sut
Hiu sut l o lng mi lin quan gia kt qu t c v nhng ph tn v ngun lc (ti chnh, thi gian ). N t c s cho vic s dng mt cch ph hp cc ngun lc v bao hm mi quan h tng h gia cc chi ph vi hiu qu ca mt chng trnh can thip. y l lnh vc m dch t hc v kinh t y t cng c ng dng. C hai phng php tip cn chnh dng nh gi hiu sut. Phn tch chi ph hiu qu (Costeffectivenes analysis) xc nh chi ph v hiu qu ca can thip hay cc phng n khc nhm xc nh mc tng i m theo cch dn n kt qu mong i. Can thip c a dng hay bin php khc l bin php i hi chi ph ti thiu nhm to ra c mt mc hiu qu cho trc. Trong lnh vc sc kho, chi ph hiu qu o lng thng qua t s gia chi ph ti chnh v hiu qu: s tin (la) trn mt nm sng t c, chi ph cho vic phng mt trng hp bnh, s tin (la) trn mt nm sng c iu chnh cht lng cuc sng t c . (Hp 10.8) Phn tch chi phli ch (costbenfit analysis) xem xt chi ph kinh t ca mt loi bnh hay chn thng xc nh v chi ph ca cng tc d phng. Bao hm trong chi ph kinh t ca mt bnh l chi ph chm sc y t v phc hi chc nng, s mt mt ca kh nng kim sng v chi ph c lng v mt x hi do t vong gy nn. Yu t sn sng chi tr (willingesstopay) c th c s dng nhm xc nh xem chi ph x hi do t vong gy nn l g: cc nc pht trin, phn tch ny cho thy gi tr ca mt cuc sng

Dch t hc, chnh sch y t v lp k hoch y t 187

vo khong vi triu la M. Trong phn tch chi ph li ch, c t s v mu s u c biu din thng qua n v tin t. Li ch ca mt chng trnh can thip v chi ph c th trnh c do cc trng hp t vong gy nn v chi ph ca can thip l chi ph trc tip ca vic trin khai cc hot ng can thip. Nu nh phn tch chi phli ch, cho thy rng li ch kinh t ca chng trnh can thip (hay li ch ca vic phng nga c thm mt trng hp) ln hn chi ph cho chng trnh, th chng trnh ny c th c nhn nh l c li ch v kinh t. Cc can thip m chi ph cao hn li ch kinh t tnh c vn c th c coi l tt v nhng thnh qu nng cao sc kho qun th m chng trnh ny mang li. Hp 10.8. iu tr b nc, in gii ng ung gi tr ng ng tin
Chi ph hiu qu cng gip cho vic xc nh cc c hi b lng qun bng cch lm ni bt cc can thip tng i r tin, nhng c tim nng trong vic lm gim gnh nng bnh tt. Mt v d in hnh l bin php iu tr b in gii ng ung. Bin php iu tr ny c tin hnh ti nh v khng s dng dch v y t v v th m gi tr hiu qu chi ph c gia tng. Mc d bin php iu tr b in gii ny khng lm gim cc trng hp mi mc tiu chy, nhng n lm gim mc trm trng v t vong c lin quan. Ch tn t 24 la trn 1 nm sng c bo ton, bin php iu tr ny c nhn nhn vi tnh gi tr cao v chnh sch cng c hiu qu. iu tr b in gii ng ung c ng dng rng ri v bo ton c hnh triu cuc sng.9

Tin hnh phn tch chi phhiu qu d hn so vi phn tch chi phli ch v o lng hiu qu khng cn thit a ra nhng gi tr v tin t. Bng 10.1 tm tt nhng chi ph c c lng cho mi nm sng c iu chnh theo tn tt (DALY) t c nh l kt qu ca cc qui trnh phng bnh mn tnh khc nhau. Cc ch s ny c gi nh l chi ph cho vic trin khai chng trnh can thip l mt hng s. Bng 10.1: D phng v iu tr bnh mn tnh khng ly: s lng sc kho m 1 triu la M c th mua c.9
Dch v hay can thip Thu nh vo cc sn phm thuc l iu tr nhi mu c tim bng cc thuc r tin iu tr nhi mu c tim bng cc thuc r tin cng vi thuc gii c t lin cu khun (Streptokinase) iu tr bnh tim mch sut i vi ch iu tr a thuc hng ngy Phu thut cho cc trng hp c th c nguy c cao Phu thut cho bnh mch vnh th nh Gi cho mt DALY ( la M) 350 1025 600750 7001000 25000+ Rt cao S DALYs phng c trn 1 triu la M 20,000 330,000 40,000100,000 1,300 1,600 1,000 1,4000 Thp hn 40 Rt thp

Mc d cc c lng trn c tnh ton da trn nhng thng tin khng tuyt i hon thin cng nh nhiu gi nh, tuy nhin n rt c ch cho nhng nh hoch nh chnh sch, l nhng ngi phi la chn u tin. Vic o lng hiu sut, i hi nhiu gi nh, v cn c s dng mt cch ht sc thn trng, y khng phi l mt o lng khng c tnh gi tr (valuefree) n ch c th c coi nh l mt hng dn tng quan.

188 Chng 10 Bng chng tt nht cho cc nghin cu chi ph hiu qu l t cc th nghim lm sng c kim sot hay r sot mt cch h thng, bng chng km thuyt phc nht l t cc nghin cu nh cc trng hp v cc iu tra ly kin chuyn gia. Ba v d lin quan n phn tch chi ph hiu qu i vi vn nhim mi trng c trnh by trong bng 9.2. Cc nh lp k hoch y t tt c cc nc thng quan tm n kha cnh kinh t ca cc chng trnh y t d kin. cc nc thu nhp thp v trung bnh, mi quan tm ny c lm ni bt do cc Mc tiu Pht trin Thin nin k (xem Chng 7) v ng thi cng do vic nhn ra rng s cng bng l mc tiu mu cht ca chnh sch y t. Cc nghin cu chi ph hiu qu c ph bin rng ri hn v d s dng hn vi cc b cng c v c s d liu theo khu vc thng qua cc d n ca TCYTTG nh CHOICE (hp 10.9) v d n u tin Kim sot Bnh.9 Hp 10.9. La chn cc can thip c tnh chi ph hiu qu: WHOCHOICE
D n WHOCHOICE kt ni cc c s d liu v cc chi ph, tc ng sc kho qun th v tnh chi ph hiu qu ca cc can thip quan trng. D n ny cng ng thi cung cp mt cng c nhm lm thch ng kt qu cp khu vc vo cc nc chuyn bit. D n cung cp cc nh phn tch c trang b cc phng php nh gi hiu sut trong mt bi cnh c th ca cc can thip ang c hoc d kin trin khai.12

Trin khai can thip

Bc th 5 trong qu trnh lp k hoch bt u bng vic hnh thnh ch cho k hoch can thip v m bo rng cc mc ch ny c th t c. Chng ta cn thc y v nhm vo cc vn c kh nng ny sinh nh l kt cc ca vic ra quyt nh. V d, nu nh chng ta d nh dng bin php chp Xquang v (mammography) nhm sng lc ung th v, ta cn m bo chc chn rng chng ta c phng tin v con ngi. Ta cng cn phi a ra cc mc ch c th c th nh lng c, chng hn nh lm gim t l mi mc ung th v th tin trin t 30% xung 20% trong vng 5 nm. Cch thc t mc ch ny rt quan trng nu nh chng ta mun nh gi s thnh cng ca can thip mt cch chnh thng. Tt nhin, trong thc t, kh c th tch ri tc ng ca mt can thip c th khi cc thay i khc trong x hi.

Theo di can thip

Bc cui cng trong qui trnh lp k hoch l theo di v o lng tin . Theo di l vic theo di lin tc cc hot ng m bo rng chng c tin hnh theo ng k hoch. Theo di cn phi ng vi cc yu cu ca chng trnh c th v nhng thnh cng ca cc chng trnh c th c o lng theo cc cch khc nhau, s dng cc tiu ch ngn hn, trung hn v di hn. i vi chng trnh chng tng huyt p ti cng ng, theo di bao gm cc nh gi nh k nh sau: o to nhn lc . Tnh sn c, xc thc ca my o huyt p (phn cu trc) S thch hp ca cc qui trnh xc nh cc trng hp (bnh) v qui trnh qun l (nh gi qu trnh) Tc ng i vi ch s huyt p cc bnh nhn c iu tr (nh gi hu qu) .

Dch t hc, chnh sch y t v lp k hoch y t 189

Bng 10.2. K hoch chm sc y t cc trng hp cao huyt p

Gnh nng Cn nguyn bnh Cc iu tra cng ng v huyt p v kim sot tng huyt p Cc nghin cu sinh thi (mui v huyt p) Cc nghin cu quan st (cn nng v huyt p) Cc nghin cu thc nghim (gim cn) Cc th nghim i chng c phn b ngu nhin nh gi chng trnh sng tuyn Cc nghin cu v tun th iu tr Cc nghin cu chi phhiu qu Chng trnh quc gia v kim sot cao huyt p nh gi v nhn vin v thit b Tc ng n cht lng cuc sng nh gi li cc mc huyt p ca qun th

Hiu qu cng ng

Hiu sut Thc hin Theo di v o lng tin

Nhm nh gi tin , ta cn tin hnh o lng li gnh nng ca bnh trong qun th. Xu hng ca cc yu t nguy c xt trn kha cnh qun th v s thu ht ca cc chng trnh can thip thng c s dng c lng tc ng ca nhiu chng trnh can thip. Gi tr y ca nghin cu dch t hc ch c thc t ho khi kt qu ca nghin cu c chuyn thnh chnh sch y t hay cc chng trnh sc kho. Chuyn bng chng thnh chnh sch vn l mt th thch ln i vi cc nh dch t hc, nhng khoa hc ny gp phn quan trng vo cng tc nh gi v lp k hoch y t.

Cu hi
10.1. 10.2. 10.3. Hy p dng cc nguyn tc ca Hin chng Bangkok v Tng cng sc khe pht trin chnh sch sc khe cng lin quan n phng ht thuc l tr em. Hy vch ra cc bc ca chu k lp k hoch chm sc y t lin quan n chn thng do ng ngi cao tui. Bn s dng cc thng s trong bng 10.2 nh th no trong vic tc ng vo cng tc lp k hoch v hnh thnh chnh sch y t nc bn?

190 Chng 10

Ti liu tham kho

1. World health report 2000: Health systems: improving performance. Geneva, World Health Organization, 2000. 2. Preventing chronic diseases: a vital investment. Geneva, World Health Organization, 2005. 3. Van Der Maas PJ. Applications of Summary Measures of Population Health. In: Ezzati M et al., eds. Summary Measures of Population Health. Concepts, ethics, measurement and applications. Geneva, World Health Organization, 2002:5360. 4. Ottowa charter for health promotion, 1986. http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf. 5. Bangkok charter for health promotion in a globalized world, 2005. http://www.who.int/healthpromotion/conferences/6gchp/bangkok_chart er/en/ 6. WHO framework convention on tobacco control. Geneva, World Health Or ganization, 2003. 7. Tugwell P, Bennett KJ, Sackett DL, Haynes RB. The measurement iterative loop: a framework for the critical appraisal of need, benefits and costs of health interventions. J Chronic Dis 1985;38:33951. Medline doi:10.1016/00219681 (85)900803 8. Bonita R, Douglas K, Winkelmann R, De Courten M. The WHO STEPwise approach to surveillance (STEPS) of noncommunicable disease risk factors. In: McQueen DV, Puska P, eds. Global Risk Factor Surveillance. London, Kluwer Academic/Plenum Publishers, 2003:922. 9. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., (eds). Disease control priorities in developing countries. New York, Oxford University Press, 2006. 10. Smith GS. Development of rapid epidemiologic assessment methods to eval uate health status and delivery of health services. Int J Epidemiol 1989;18:S215. Medline 11. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): casecontrol study. Lancet 2004;364:937952. Medline doi:10.1016/S01406736(04)170189 12. Baltussen R, Adam T, Tan Torres T, Hutubessy R, Acharya A, Evans DB, et al. Generalized costeffectiveness analysis: a guide. In: Jones AM, ed. The Elgar Companion To Health Economics, Edward Elgar Press; 2006: 479491.

191

Chng 11

Cc bc u tin trong dch t hc thc hnh

Thng ip chnh
Con ng s nghip y th v trong dch t hc ph thuc vo s mong mun hiu bit nhiu hn v bnh v cc yu t nguy c. Bit c cch thu thp ti liu c v cch nh gi tnh ph hp v tnh gi tr l mt phn quan trng ca vic tip cn lin tc vi ci mi. Lm tt cc nghin cu dch t hc ph thuc vo vic a ra c cu hi nghin cu tt, vit cng mch lc, c xt duyt v o c v ng ti, cng nh p dng c kt qu nghin cu. Cng vic ny c th t c d dng hn qua vic s dng cc ngun lc min ph trn mng internet bao gm cc c s d liu, cng c phn tch, ti liu thao kho v hng dn ging dy.

Gii thiu
Nu cun sch ny thnh cng, bn s say m ng dng cc kin thc hc vo cc cng vic thc t lin quan n dch t hc. lm c iu ny, bn phi lun m rng tm nhn hc hi v lun lun tm ti cc cu hi nghin cu tt. Bn cn phi suy ngh v vic lm sao c th s dng ng thit k nghin cu tr li cho cu hi nghin cu ca mnh (chng 3), lm cch no cng c duyt v xin c ngun ti tr, lm sao m bo chc chn rng vn ny cha c tin hnh, lm cch no lm nghin cu tt v cng nh cch vit, trnh by v ng ti kt qu nghin cu ca mnh.

Cc bnh c th
Chng ta c th bt u bng vic hiu bit lin tc v cc bnh c th hay cc vn Y t cng cng. Hiu bit c bn v dch t hc ca bnh c lit k trong bng 11.1. Cc bnh him, ni cm, hay bin i nhanh thng c coi l i tng ca nghin cu nhm thit lp cc c tnh quan trng ny. Bn cn tip tc tm ti v hc hi nhm hon thin kin thc dch t hc thng qua vic b sung cc kin thc mi v bnh hc, iu tr lm sng, dc hc cng nh phc hi chc nng v tc ng kinh t ca bnh. S hiu bit chi tit hn v kha cnh k thut hay v sinh ca d phng, tc ng kinh t hay xu hng thay i c th cn thit cho cc lnh vc c th ca thc hnh y t cng cng. Thay v tp trung vo mt bnh c th, bn c th tp trung vo mt yu t nguy c c th chng hn nh ht thuc hay phi nhim vi thuc dit cn trng. Vic ny

192 Chng 11 bao gm c nghin cu y vn v lm nghin cu v ng phi nhim ca mt yu t nguy c c th no i vi con ngi, cng nh c ch m theo n tc ng n sc kho con ngi (Bng 11.2).

Bng 1 1.1 Cc thng tin dch t hc c bn ca mt bnh

Lch s t nhin trong tng c th:

Pht trin theo tui (c s ca nhm thun tp) Cc ch s sm ( sng lc) Tc ng ca cch iu tr khc nhau Kh nng iu tr Cc nhu cu chm sc Tc ng x hi

Cn nguyn bnh:
Cc yu t cn nguyn c th Cc yu t nguy c khc

Pht trin trong cng ng:

Xu hng thi gian S khc nhau v tui (trn c s nghin cu ct ngang)

S khc nhau trong s xut hin:

Gii tnh Nhm dn tc Tng lp x hi Ngh nghip Khu vc a l

Kh nng d phng:
Cc bin php c th chng li cc yu t cn nguyn Cc bin php chung chng li cc yu t nguy c khc. Tc ng ca dch v y t bao gm sng lc v pht hin sm Tc ng ca chnh sch y t

c c ph phn
Nm bt cc thng tin cp nht, ngay c trong lnh vc chuyn khoa hp, l rt kh bi v s lng ln ca cc ti liu c ng ti. Tm kim, phn loi v hiu cc thng tin c gi tr v ph hp l k nng quan trng m ch c c thng qua thc hnh nhiu. Tuy nhin, n lc b ra hc cch nhn nh cc bi bo s c n p khi ta tin hnh thit k nghin cu p dng cho cc cu hi nghin cu tng t. Mt cch tip cn l trc tin cn phn loi cc bi bo thnh nm phn loi rng phn ln cc bi bo nghin cu dch t hc l v lch s t nhin ca bnh; s phn b theo a l ca bnh; nguyn nhn gy bnh; hay cc xt nghim chn on. Cp ca bng chng m bt c nghin cu chuyn bit no cng c th cung cp c kt ni vi thit k ca nghin cu . Nhn chung, mc ca bng chng c xem xt t kin chuyn gia, cho n nghin cu trng hp, n cc nghin cu thun tp, th nghim lm sng c kim sot v r sot c h thng (systematic

Cc bc u tin trong dch t hc thc hnh 193 review), nhng iu quan trng l phi xt n cht lng v gi tr ca bt c v d no bn cnh vic xem xt v tr tng i ca loi thit k nghin cu. Khi c bi bo bn c th cn nhc cc cu hi c xp xp theo trnh t nh sau: Bng 11.2. Thng tin dch t hc c bn v tc hi
ng lc thc y chnh sch kinh t pht trin cng ngh Ngun tc hi cc qui trnh c th tc ng ca cc yu t khc bin i theo ngy v theo ma xu hng lch s v a l Yu t tc ng n mc phi nhim ln con ngi tui, gii, s khc bit v chng tc ch n, hot ng th lc yu t thi tit hot ng cng vic Cc yu t hnh vi khc V d lut qung co thuc l thu nh vo thuc l, lm gi thuc l my xc tc lm gim nhim khng kh t than v nhim khng kh cc yu t thu vn v nhim khng kh cc mc zn nh hng sc khe C ch nguyn nhn Nhng du hiu ha sinh hoc sinh l v nh hng Bin pht phng phi nhim v nh hng sc khe

Cu hi nghin cu l g ?
Bc u tin i vi bn c l xc nh cc mc tiu ca nghin cu, tc l cu hi c cp hoc gi thuyt mong mun c th nghim.

Nu cc kt qu c gi tr th n c ph hp vi cng vic ca ti khng?

Nu c, hy tip tc c. Nu khng, bt u li vi bi bo khc.

Nghin cu ny thuc loi g?

Cc nghin cu ct ngang cp n cc cu hi v tnh trng hin mc bnh hay yu t nguy c. Cc nghin cu thun tp cp n cc cu hi v lch s t nhin hay tin lng v cn nguyn ca bnh. Nghin cu bnh chng hay nghin cu thun tp xc nh cc yu t cn nguyn tim tng. Cc nghin cu th nghim lm sng c kim sot thng l thit k nghin cu ph hp nht cho vic tr li cc cu hi v hiu lc ca bin php iu tr hay cc can thip khc.

Qun th nghin cu l qun th no?

Ai l nhng ngi c a vo nghin cu v b loi ra khi nghin cu? Cc i tng nghin cu c phi l mu ca qun th ch khng?

194 Chng 11 Nu khng, th ti sao? Mu c chn nh th no? C bng chng ca vic chn ngu nhin khng, i li vi s la chn mt cch h thng hay t la chn? C ngun sai lch tim tng no trong khu chn mu khng? Kch thc mu c ln tr li cc cu hi nghin cu c cp khng?

i vi nghin cu thc nghim, c m t k cc phng php s dng khng?

Cc i tng nghin cu c phn b vo cc phng thc iu tr nh th no: mt cch ngu nhin hay l theo cch no khc? Kiu/loi nhm chng no c s dng (gi dc, nhm khng iu tr lm chng, c hai hoc khng c nhm chng)? Cc phng thc iu tr c so snh th no? Cc o lng c c m bo bng cc qui trnh m bo cht lng khng? Gi thuyt trong nghin cu c c nu mt cch r rng bng cc thut ng thng k khng? Phn tch thng k c ph hp khng v n c c trnh by mt cch chi tit v y khng? Nu y l th nghim lm sng c kim sot, nghin cu c c p dng qui trnh phn tch Ch chnhmiu tr (intentiontotreat), tc l tt c mi ngi tham gia nghin cu c c tnh m n trong khu phn tch khng? Kt qu hay tc ng c c o lng mt cch khch quan khng?

i vi cc nghin cu quan st, c m t chi tit cc phng php khng?

Qu trnh thu thp s liu c ph hp (bao gm c khu thit k b cu hi v th nghim b cu hi) K thut no c dng x l tnh trng khng hp tc hay khng p ng ca i tng nghin cu, hay s liu khng y ? Nu l nghin cu thun tp th t l theo di c c cao khng? Nu l nghin cu bnhchng th nhm chng c ph hp khng, c c ghp cp tt khng?

S liu c trnh by nh th no?

C trnh by s liu y r rng theo biu, bng khng? Cc s c thng nht khng? Ton b mu nghin cu c c tnh m n khng? lch chun c c trnh by vi trung bnh, khong tin cy, h s hi qui tuyn tnh hoc cc ch s thng k khc cng nh s liu th khng?

nh gi v phin gii kt qu
Nu nh bn thy rng nghin cu bn ang c c tnh gi tr v ph hp th ta s tip tc nh sau. Nu l mt nghin cu thc nghim,

Cc bc u tin trong dch t hc thc hnh 195 Cc tc gi c tm thy s khc bit gia cc nhm iu tr v chng/kim sot khng? Nu nh khng c s khc bit, bn c th loi b vai tr ca sai s loi II (Type II error) (xem Chng 4) dn n vic cho rng y l nghin cu m tnh (negative study) iu ny khng c ngha l kt qu nghin cu khng mang li iu g. Nu nh cc tc gi tm thy s khc bit th bn c tin chc rng kt qu ny l khng phi do ngu nhin (sai s loi I, xem chng 4), hay sai chch (sai s h thng)? Nu nh c tn ti s khc bit th s khc bit ny c mang li ngha lm sng hay khng?

Nu l m tnghin cu quan st Cc pht hin trong nhm chng c nht qun vi k vng ca bn khng cc gi tr trung bnh c ging nh qun th chung khng? Tc gi c tm thy s khc bit gia nhm phi nhim v nhm khng phi nhim (chng) hay gia cc nhm bnh v chng hay khng? Sai s loi I v loi II c th c loi b hay khng? C s khc bit c ngha thng k gia cc nhm khng? Cc kt qu ny c ngha v mt Y t cng cng khng, thm ch s khc bit khng c ngha thng k? (iu ny c th lm cho vic cn thit c nghin cu ln hn c thit k v trin khai)

nh gi cui cng
Cc cu hi di y c th c hi cn nhc cc bng chng Cc cu hi nghin cu c ng gi khng v hu qu ca nhng cu tr li khc nhau c th c s nh th no? Nghin cu c a ra c khuyn ngh hnh ng no khng? Tc gi c s c gng ph hp no khng tr li cc cu hi nghin cu? Thit k nghin cu c th c ci thinkhng? Thng tin b mt c cn tr vic nh gi mt cch y nghin cu khng? Tc gi c tnh m ti cc kt qu ca cc nghin cu trc y i khng?

Xy dng k hoch cho nghin cu

Trong nhiu kha hc v dch t hc c bn, cc sinh vin c giao nhim v thit k nghin cu. Trong mt vi tnh hung, cc bi tp c nng cao v sinh vin c k vng rng h phi thc hin nghin cu v phn tch s liu ca nghin cu , mc d yu cu ny thng ch dnh cho cc sinh vin sau i hc. y hon ton l mt s tin trin t nhin t vic c c phn phn cho n vic thit k nghin cu. Thit k nghin cu vi s gim st ph hp, v s h tr ca ging vin c kinh nghim l phng php tt hc v cc nguyn l v phng php dch t hc. Cc bc trong vic xy dng k hoch cho mt nghin cu bao gm: chn ti vit cng nhn ph duyt tin hnh nghin cu

196 Chng 11 phn tch s liu cng b kt qu nghin cu.

La chn mt ti hay ch nghin cu

Gio vin hng dn phi ng vai tr tch cc trong vic la chn cc ch v tip xc vi cc thnh vin ti cng ng. ti ca sinh vin khng nn qu tham vng v thi gian ngn v ngun lc t. L tng nht l cc ti phi c ngha ti a phng, c lin quan n mt s c s y t l ni s c ngi c th cng tham gia nh l gim st vin cng tc. Cc d n nghin cu ca sinh vin c th tp trung vo mt lot cc ch sau: nhim mi trng v cc nguy c tim tng nh hng n sc khe quanh x nghip t cht thi; Thi v hnh vi lin quan n vic i m bo him S dng mn chng mui t Bo qun ho cht tr su S dng dch v trc sinh ca cc b m sinh con ln u.

Vit cng nghin cu

Khi tham kho y vn mt cch cn thn v k lng v mt khi bn m bo rng nghin cu m bn d kin cha c tin hnh hay ng c nhc li, bn cn phi vit cng nghin cu. Bn cn tham kho cc hng dn thng nht v ph hp i vi loi nghin cu bn mun lm m bo chc chn rng bn khng b st im g (Bng 11.3). Ni chung, mt cng nghin cu cn gii thch c: Bn d nh mun lm g: m t r vn v cch tip cn gii quyt vn . Minh chng khng nh cho tm quan trng ca cu hi nghin cu v vic nghin cu ng gp nh th no vo kin thc nhn loi. M t qun th, a bn nghin cu, thit k can thip hay quan st. Chi tit thit k nghin cu d kin s dng bao gm: chin lc chn mu s i tng nghin cu bin s quan tm, bao gm c cc bin nhiu tim tng phng php thu thp s liu, bao gm c th nghim trc khi tin hnh nghin cu. qui trnh m bo cht lng ghi nhn s liu v qun l s liu x l v phn tch s liu Kinh ph v k hoch trin khai (bao gm c ngun kinh ph v tt c cc ngun cn thit khc) Vai tr v trch nhim ca tt c nhng ngi tham gia nghin cu. Hi ng xt duyt o c, ti ngi m cng s c gi n nhn s ph duyt. K hoch ng ti: cch thc bn s cng b v p dng kt qu K hoch phn hi ti cng ng.

Cc bc u tin trong dch t hc thc hnh 197

Bng 11.3. Hng dn thng nht v cch thc xy dng thit k nghin cu v vit bo co
Lnh vc Tc quyn Hng dn Hng dn Vancouver (U ban quc t nhng nh bin tp tp ch y hc) COPE MOOSE TREND CONSORT Tuyn b Hensingki STARD QUOROM a ch web http://www.icmje.org/index.html

o c ng ti tng qut Phn tch meta ca cc nghin cu quan st Th nghim can thip khng phn b ngu nhin o c nghin cu trong th nghim lm sng c kim sot Nghin cu tnh xc thc ca chn on R sot c h thng v phn tch meta cc nghin cu th nghim lm sng c kim sot

http://www.publicationethics.org.uk http://www.consort statement.org/news.html#moose http://www.ajph.org/chi/content/full/94/3/361 http://www.wma.net/e/policy/b3.htm

http://www.consort statement.org/stardstatement.htm http://www.consort statement.org/evidence.html#quorom

cng nghin cu cn c s nghin cu cn trng v y chnh l c s cho vic tm kim ngun kinh ph v ph chun o c cho nghin cu ca bn. Mt s tp ch yu cu c nh gi ca ng nghip i vi cng nghin cu, tng t nh i vi bi bo. Mi ngi lm theo nhiu cch khc nhau, nu cng nghin cu ca bn qua c khu nh gi ca ng nghip v c tp ch ng ti th cc bin tp vin cng s thng tin hnh r sot bi bo c ng cc kt qu chnh ca nghin cu ny.

Tin hnh nghin cu

Mt khi cng chun b, cng cn c chuyn cho mt s ngi c kinh nghim gp v cn c hiu nh li. i vi phn ln cc nghin cu dch t hc, thng c khong thi gian di gia khu chun b cng, v bt u trin khai nghin cu. Cc nghin cu ca sinh vin, tuy nhin, phi c thit k lm sao h c th thc hin nhanh chng v c hiu qu v thi gian thng c hn. Cc ti ca sinh vin phi khng nn cn qu nhiu ngun lc, ngi hng dn phi c trch nhim lm sao c c nhng g cn thit cho nghin cu. Ngi hng dn cng phi chu trch nhim trnh ti cho hi ng o c c chp thun vo ng thi gian. Cc ti lm theo nhm cn phn chia hp l cc cng vic v thng c li nu mt ngi trong nhm chu trch nhim lin h vi hng dn vin. Qu trnh trin khai nghin cu phi c xem xt thng xuyn v cn phi c thi gian th nghim cc cu hi phng vn v th nghim chn mu v qu trnh thu thp s liu.

198 Chng 11 ti phi kt thc bng mt bui trnh by trc ton lp (c th din tp trc), sau lm bo co, c th a cho nhng ngi quan tm c. Bo co c th c s dng cho mc ch ging dy, hoc l c s cho cc nghin cu tip theo.

Phn tch s liu

Phn ln cc phn tch thng k hin nay c tin hnh vi s tr gip ca cc phn mm vi tnh. C mt lot cc la chn phn mm khc nhau cho thng k v dch t hc, t cc bng tnh trong my tnh c th dng phn tch trong phm vi c hn, t cc phn mm dng cho cc phn tch c th cho n phn mm dng cho mi mc ch v c th x l c gn nh tt c cc phn tch thng k cn thit cho cc nghin cu dch t hc. C mt danh mc gii thiu cc ti nguyn dch t hc min ph hoc chi ph thp do nhm Theo di dch t hc (Epidemiology monitor) cung cp (http://www.epimonitor.net). Chng trnh Episheet c th ly t a ch http://77www.oupusa.org/epi/rothman. Cc chng trnh phc v cng cng nh OpenEpi hay chng trnh Epi InfoTM cng min ph; hoc cc chng trnh thng mi c gi ln n mt vi nghn la M. Khi la chn cc phn mm bn cn phi nh gi xem kh nng ca phn mm nhp s liu x l s liu b mt, cp nht v kt ni b s liu, cng nh cc loi phn tch m phn mm c th lm c, cng vi cc chc nng khc nh vit bo co, ho v v bn .

Chun b ng ti
Bn cn phi ngh v vic bn s ng ti nghin cu ca bn u ngay t cc giai on lp k hoch cho nghin cu. Cch thc tt nht nhm gii qut vng mc lin quan n tc quyn l trc tin cn phi trnh, c ngha l cn quyt nh sm v vic ai s l ngi trong nhm nghin cu l tc gi ca bi bo v phn cc c nhn trong nhm phi vit l bao nhiu. Hng dn vit bi ng ti tp ch thng cha ng cc thng tin rt c ch v thit k v cc c tnh k thut cho vic vit bo co, v rt nhiu trong s cc c tnh k thut ny khng th iu chnh li trong qu kh. Bn cn phi t vn, tham kho cc hng dn ph hp (xem bng 11.3) vi loi nghin cu bn ang lm v m bo rng cng nghin cu ca bn bao trm ht cc im ny. Ni ti tr cho nghin cu ca bn c th t iu kin rng bn phi ng ti cc tp ch m tt c mi ngi c th tip cn c v bn s phi ng k nghin cu thc nghim v c ph chun cho ng k nhm tho mn nhng yu cu ti thiu cho vic ng ti cc tp ch ln.

c thm
Ti liu c lin quan n dch t hc khng thiu. Bng 11.4 l danh mc cc tp ch c ng nghip nh gi. Nhiu nghin cu dch t hc c ng ti cc tp ch y hc tng qut v mt s cc tp ch trong s ny c chnh sch cung cp thng tin min ph trn internet cho mt s nc ang pht trin. Tt c cc ni dung ca cc tp ch m thng min ph i vi ngi c v TCYTTG trin khai hot ng hp tc vi cc nh xut bn ln cung cp min ph hay vi gi r cc ni dung ca cc tp ch ca h cho cc c s cc nc ang pht trin. Hot ng hp tc ny c gi l sng kin HINARI (Hp 11.1).

Cc bc u tin trong dch t hc thc hnh 199

Hp 11.1. Tip cn sng kin nghin cu thng qua kt ni h thng mng sc kho (The health InterNetwork Acces to Research Initiative HINARI)
Sng kin HINARI cho php cc c s phi li nhun cc nc ang pht trin tip cn min ph hoc chi ph thp qua Internet vo cc tp ch ln v cc lnh vc y sinh hc, khoa hc x hi. c thnh lp thng 1 nm 2002, hn 70 nh xut bn cung cp cc ni dung ca h cho HINARI. Cc c s tham gia d n ny cn c my tnh kt ni Internet tc cao. Chi tit v vic ng nhp c th tm thy trn a ch web ca TCYTTG (http://www.who.int/hinari/en).

Bng 11.4. V d mt s tp ch c ng nghip nh gi c ng ti nghin cu dch t hc

American Journal of Epidemiology American Journal of Public Health Annals of Epidemiology Bulletin of the World Health Organization Cadernos de Sade Pblica Emerging Infectious Diseases Environmental Health Perspectives Environmental Research Epidemiologia e prevenzione Epidemiological Reviews Epidemiology European Journal of Epidemiology International Journal of Epidemiology Journal of Clinical Epidemiology Journal of Epidemiology and Community Health Public Library of Science Medicine Revista de Sade Pblica Revista Panamerican de Salud Publica Revue dpidmiologie et de sant publique The British Medical Journal The Lancet Weekly Epidemiological Record http://aje.oxfordjournals.org/ http://www.ajph.org/ http://www.annalsofepidemiology.org/ http://www.who.int/bulletin/en/ http://www.ensp.fiocruz.br/csp/ http://www.cdc.gov/ncidod/EID/ http://www.zadig.it/eprev/ http://epirev.oxfordjournals.org/ http://www.epidem.com/ http://www.springerlink.com/link.asp?id= 102883 http://journals.elsevierhealth.com/periodicals/jce http://jech.bmjjournals.com/ http://medicine.plosjournals.org http://www.fsp.usp.br/rsp/ http://revista.paho.org/ http://bmj.bmjjournals.com/ http://www.thelancet.com/ http://www.who.int/wer/en/

Bng 11.5 l danh mc mt s sch nng cao. Cc t chc phi chnh ph v chnh ph hoc lin chnh ph cng ng ti khi lng ln thng tin dch t hc quan trng v y cng l ngun thng tin ng k v mt ch chuyn bit. Bng 11.5. Mt s sch gi cho vic c thm v dch t hc
Baker D, Kjellstrom T, Calderon R, Pastides H, eds. Environmental epidemiology. Document WHO/SDE/OEH/99.7, Geneva, World Health Organization, 1999. (order from: SMI Books, Stevenage, United Kingdom, webmaster @ earthprint.com) Bradford Hill A. Principles of Medical Statistics, 12th ed. Lubrecht & Cramer Ltd, 1991 Checkoway H, Pearce N, CrawfordBrown D. Research methods in occupational epidemiology. New York, Oxford University Press, 1989. Coggon D, Rose G, Barker DJP. Epidemiology for the uninitiated. London, BMJ Publishing Group,1997. http://bmj.bmjjournals.com/collections/epidem/epid.shtml

200 Chng 11
Detels R, McKewen J, Beaglehole R, Tanaka H. Oxford Textbook of Public Health. 4th edition. New York, Oxford University Press, 2002. (ISBN: 0 192 630 415) Friss RH, Sellers TA. Epidemiology for public health practice. Maryland, Aspen, 1996. Gordis, Leon. Epidemiology, 2nd ed. Philadelphia, Saunders, 2000. Halperin W, Baker EL Jr., Monson RR. Public health surveillance. New York,Van Nostrand Reinhold, 1992. Kahn HA. Statistical methods in epidemiology. New York, Oxford University Press, 1989. Kleinbaum DG, Barker N, Sullivan KM. ActivEpi Companion Textbook, Springer, 2005. (ISBN: 0 387 955 747) Lilienfeld DE, Stolley PD. Foundations of epidemiology, 3rd ed. New York, Oxford University Press, 1994. MacMahon B, Trichopolous D. Epidemiology: Principles & Methods, 2nd ed. Boston, Little, Brown, 1996. (ISBN 0 316 542 229) MacMahon B. Epidemiology: principles and methods. 2nd ed. Hagerstown, LippincottRaven, 1997. Mausner JS, Kramer S. Mausner & Bahn Epidemiology: an introductory text. Philadelphia,W.B. Saunders, 1985. Meinert, CL. Clinical trials: design, conduct, and analysis. New York, Oxford University Press, 1986. Morton RF, Hebel JR, McCarter RJ. A study guide to epidemiology and biostatistics. Jones and Bartlett Publishers; 2004. (ISBN: 0 763 728 756) Norell SE A short course in epidemiology. New York, Raven Press, 1992. (ISBN 0881678422) Pearce N. A short introduction to epidemiology. Occasional Report Series 2. Wellington, Centre for Public Health Research. (ISBN: 0 473 095 602) Petitti, Diana B. Metaanalysis, decision analysis, & costeffectiveness analysis: methods for quantitative synthesis, 2nd ed. Oxford University Press, 2000. (ISBN: 0 195 133 641) Rothman KJ, Greenland S. Modern Epidemiology Lippincott Williams & Wilkins; 1998 (ISBN: 0 316 757 802) Rothman KJ. Epidemiology: An Introduction. New York, Oxford University Press, 2002. (ISBN: 0 195 135 547) Sackett DL, Haynes RB, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. New York, Little, Brown, 1985. Szklo M, Nieto FJ. Epidemiology: beyond the basics. Gaithersburg, Aspen, 2000. (ISBN: 0 834 206 188) WassertheilSmoller S. Biostatistics and Epidemiology: A Primer for Health and Biomedical Professionals Springer, 2004. (ISBN: 0 387 402 926)

Tip tc o to
C nhiu kha hc o to sau i hc v dch t hc (Xem bng 11.6 v cc ng kt ni). Cc kho hc vo ma h, v d kho 3 tun Dch t hc trong thc hnh do C quan Y t cng cng Canada cung cp rt ph bin Bc M. Chng trnh o to dich t hc can thip Chu u (EPIET) l mt chng trnh tt cung cp cc kho hc tng t Chu u, t chc TEPHINET (Network of Training Programs in Epidemilogy and Public Health Intervention) cung cp cc kho hc 32 nc. Cc kho hc dch t hc nng cao thng l mt phn ca chng trinh Thc s y t cng cng do cc trng i hc cung cp trn ton th gii. Mt ngun khc na l dich t hc Supercourse l mt th vin cng cng cc bi ging dch t hc vi s ng gp ca 151 nc trn th gii v c dch ra 8 th ting.

Cc bc u tin trong dch t hc thc hnh 201 Bng 11.6. Mt s kt ni n cc phn mm v kha hc dch t
Annual Summer Programme in Epidemiology and Biostatistics, McGill University Annual Summer Session for Public Health Studies, Harvard University Annual Summer Session in Epidemiology, The University ofMichigan Canadian Field Epidemiology Program Chinese Education and Reseach Network Course material for Epiinfo Critical Appraisal Skills Programme Free Epidata software Free public health software Interactive Statistical Pages Project Karolinska Institutet Open source software Public domain Epiinfo software Summer Program in Intermediate Epidemiology and Biostatistics, PAHO Textbook and CD demo The Epidemiology Supercourse The Erasmus Summer Programme, Erasmus University Rotterdam The European Programme for Intervention Epidemiology Training The Johns Hopkins Graduate Summer Program in Epidemiology The Network of Training Programs in Epidemiology and Public Health Interventions Ume International School of Public Health University of Alabama Masters in Public Health Biostatistics Course http://www.mcgill.ca/epibiostat/ http://www.hsph.harvard.edu/summer/br ochure/ http://www.sph.umich.edu/epid/GSS/ http://www.phacaspc.gc.ca/cfep pcet/summer_c_e.html http://www.cernet.edu.cn/ http://www.epiinformatics.com/Resourc es.htm http://www.phru.nhs.uk/casp/casp.htm http://www.epidata.dk http://www.brixtonhealth.com/ http://statpages.org/ http://www.bioepi.org/ http://www.openepi.com/Menu/OpenEpi Menu.htm http://www.cdc.gov/Epiinfo/ http://www.paho.org/english/sha/shaforr ec.htm http://www.activepi.com/ http://www.pitt.edu/~super1 http://www.erasmussummerprogramme. nl/ http://www.epiet.org/ http://www.jhsph.edu/summerEpi http://tephinet.org/ http://www.umu.se/phmed/epidemi/utbil dning/index.html http://statcourse.dopm.uab.edu/

Cu hi
1. on di y da trn bo co s b ca mt nghin cu trong vic nh gi gi tr ca aspirin trong vic d phng bnh ng mch vnh c in trong Tp ch y hc New England (New England jourrmal of medicine). Nghin cu v sc kho ca thy thuc l mt nghin cu phn b ngu nhin m kp, dng th nghim lm sng vi nhm i chng s dng gi dc nhm kim nh vic dng 325 mg aspirin mi ngy lm h t l t vong do bnh tim mch. Tiu chun la chn ngi tham gia nghin cu l tt c nhng thy thuc nam gii t 40 n 84 tui M vo thi im bt u nghin cu t nm 1982. Nhng th mi, giy ng cam kt tham gia nghin cu, v nhng cu hi cho iu tra c bn c chuyn theo th cho 261.248 thy thuc da trn

202 Chng 11 danh sch ca ca Hi y hc M. Ngay t 31/12/1983, c 112.528 trng hp tr li, trong 59.285 ngi t nguyn tham gia nghin cu. Mt s lng ln b loi tr trong giai on ng k, bi v c mt s t thy thuc khng chp nhn phng thc iu tr (phi dng thuc), mt s c tin s chy mu d dy, v mc dung np thuc km cng b loi ra. Cui cng c 11.037 thy thuc c phn b ngu nhin ung aspirin tht, v 11.034 ngi ung gi dc. Nghin cu ny cho thy aspirine c hiu qu tt trong phng chng nhi mu c tim khng gy t vong. Vy liu bn c k n dng aspirin d phng bnh ng mch vnh khng? 2. on sau y l tm tt t ti liu ni v t l t vong do hen New Zealand, c xut bn trn tp ch Lancet (Wilson v cng tc vin 1981).

Tm tt
Trong 2 nm qua, Auckland ghi nhn s tng nhanh r rt nhng ngi tr tui cht t ngt do bnh hen cp tnh. C 22 trng hp t vong c xem xt. Cc thi quen k n thuc iu tr bnh hen c thay i New Zealand cng vi s gia tng ng k vic dng thuc theophyline dng ung, c bit l cc loi ch phm c tnh bn vng o thi chm trong nhiu bnh nhn dng thay loi steroit dng ht, v cromoglycate. C kin cho rng c l c s nhim c cng thm gia theophvline v 2 acgonists dng ht liu cao, dn ti tnh trng ngng tim.

Phng php
Chi tit v cc ca t vong do hen c thu thp t cc chuyn gia bnh hc ng mch vnh, do Hi bnh hen Auckland, cc bc s thc hnh, cc khoa hi sc ca bnh vin Auckland. Bc s v ngi nh ca bnh nhn c nhng tip xc v m t cc hon cnh t vong ca bnh nhn, v cc loi thuc dng. Thng k cc trng hp cht do hen New Zealand nhn c trong nhng nm 1974 1978 ti B y t ca New Zealand. Khm nghim t thi c tin hnh 8 bnh nhn c lin quan n bnh mch vnh. Trn c s ca cc phng php , liu bn c ng cho rng tng tc c tnh ca thuc dn n tng nguy c t vong khng?

Tr li cu hi 203

Chng 1
1.1. Thc t s trng hp b t mt qun cao gp bn mi ln so vi s lng mt qun khc khng phn nh nguy c nhim t hai qun. So snh s lng t vong l khng ph hp v qun th dn c do cng ty Southwark cung cp nc ln gp tm ln so vi qun th dn c do cng ty Lambeth cung cp nc. Cn phi so snh t l t vong (s lng t vong chia cho qun th dn c c cung cp nc). Trn thc t t l t vong qun th do cng ty Southwark cung cp nc ln gp nm ln so vi t l t vong do cng ty Lambeth cung cp nc. 1.2. Bng chng tt nht l t cc nghin cu can thip. V dch nm 1854 c kim sot theo cch n tng nht khi loi b tay cm ca my bm nc. Dch c kim sot mt cch nhanh chng, mc d bng chng cho rng (v Snow cng bit) dch gim i trc khi c hnh ng ny. Bng chng thuyt phc hn l vic gim t l mc t qun th dn c do cng ty Lambeth cung cp nc trong thi k 18491854 (trc khi c dch) sau khi cng ty ny chuyn sang ly nc t on t b nhim hn ca Sng Thame. 1.3. Cc bc s l nhm i tng nghin cu tt bi v h thuc nhm ngh nghip c nh ngha r rng v c iu kin kinh t x hi tng t nhau v vic theo di h tng i d dng. H cng c nhiu kh nng quan tm n vn sc khe v hp tc tt trong loi nghin cu ny 1.4. Ngi ta c th kt lun rng t l t vong do ung th phi tng mt cch ng ch cng vi s lng thuc l ht. Ch da vo s liu khng thi th cha th kt lun rng ht thuc gy ung th phi; mt s yu t khc c lin quan ti ht thuc l c th gy ra ung th phi. Tuy nhin, nm 1964 trn c s ca nghin cu ny v nhiu nghin cu khc, Hi Y hc M kt lun rng ung th phi l do ht thuc l gy ra. 1.5. Phn b ca qun th l yu t u tin phi cn nhc. Mt ca cc ca bnh mt khu vc ch ng quan tm khi qun th dn c dn tri trn ton b khu vc . Th hai, cn bit xem liu vic tm kim cc trng hp bnh cc khu vc khng c bnh cng nghim tc nh nhng khu vc c bnh. Trong khi bng n v dch bnh Minamata, vic tm kim cc ca bnh c tin hnh trn sut c khu vc v ngi ta thy rng mt vi trung tm dn s ln khng c ca bnh no. 1.6. S kin st thp khp c bo co v ang gim i mt cch ng k an Mch t u nhng nm 1900. S gim i ny c th l s thc mc d iu quan trng l c gng loi b nh hng ca nhng thay i trong cch chn on v thc hnh bo co. T khi liu php iu tr y hc st thp khp hiu qu tr nn sn c v ph bin vo nhng nm 1940, th hu ht nhng suy gim ny c quy cho nhng ci thin v iu kin kinh t x hi, v d nh v dinh dng. Cng c mt kh nng c th xy ra l sinh vt gy bnh tr nn t c tnh hn. 1.7. Nhng ngi n ng khng ht thuc v khng phi nhim vi bi aming c t l ung th phi thp nht, tip n theo trt t tng dn l nhng ngi c phi nhim vi bi aming v khng ht thuc, nhng ngi ht thuc nhng khng phi nhim vi bi aming v cui cng l nhng ngi c ht thuc v phi nhim vi bi aming. y l v d v s tng tc trong hai yu t cng tc ng vi nhau ti ra t l mc bnh rt cao. T quan im y t cng cng, iu quan trng l m bo rng nhng ngi phi nhim vi bi aming khng ht thuc v tt nhin, gim phi nhim vi bi aming.

204 Ph lc

Chng 2
2.1. Ba loi o lng l hin mc, mi mc v mi mc tch ly. Hin mc l t l qun th chu tc ng ca mt loi bnh hay tnh trng trong mt khong thi gian v xp x bng mi mc nhn vi khong thi gian ko di ca bnh. Mi mc o lng t sut xut hin mt s kin mi trong qun th; mi mc tnh n khong thi gian thay i m trong mt c th khng mc bnh. Mi mc tch ly o lng mu s (hay qun th nguy c) ti mt thi im (thng l im bt u nghin cu) v t o lng nguy c cc c th c bnh trong mt khong thi gian xc nh. 2.2. Hin mc l mt o lng hiu qu v tn s tnh trng tiu ng khng ph thuc vo insulin v mi mc tiu ng tng i thp v thng cn c mt qun th rt ln cng vi thi gian nghin cu di mi c th xc nh s trng hp mi o lng mi mc. Thay i trong Bng 2.3 phn nh nhng khc bit trong o lng. Cn nh gi chnh xc ca cc phng php s dng trong cc iu tra khc nhau; trong s nhng yu t khc, cng cn xem xt n t l p ng/tham gia iu tra cng nh cc phng php xt nghim ti phng th nghim. Tuy nhin, cng cn ch mt iu l cc tiu ch chun c p dng l da trn mc glocose trong mu sau khi dung np lng glocose chun. Nhiu kh nng nhng bin thin v hin mc tiu ng ny l thc s t nht l do nhng thay i v ch dinh dng, tp th dc v cc yu t v li sng khc. 2.3. Nguy c quy thuc qun th hay phn s nguy c (qun th) c tnh nh sau:

30,2 17,7 = 0,414 30,2

Tng ng vi 41,4%. 2.4. Khc bit nguy c v t s nguy c. 2.5. Mc d nguy c tng i ch khong 1,5, nguy c quy thuc qun th l 20% (ngha l khong 20% s trng hp ung th phi trong qun th ca mt nc pht trin c th quy cho nguyn nhn l ht thuc l th ng). L do l c n ti a mt na qun th l c phi nhim vi ht thuc l th ng. 2.6. Chun ha theo tui m bo rng nhng khc bit v t sut t vong khng phi l do khc bit v phn b tui gia cc qun th. Chun ha t sut th loi b khc bit v phn b tui ra khi bc tranh v do cho php so snh gia cc qun th c cu trc tui khc nhau bng cch ly mt qun th c phn b tui chun. 2.7. C t sut hoc s t vong do ung th u c th s dng. Tt c ch ty thuc vo cch phin gii thng tin. S trng hp cho chng ta bit vng no ca quc gia c s trng hp ung th cn iu tr ln nht. T sut th cho chng ta bit a phng c s trng hp trn u ngi ln nht, nhng t sut th cao cng c th cho bit c nhiu ngi cao tui vng . Tuy nhin, t sut chun ha theo tui cho chung ta bit a phng c nguy c ung th cao nht, bc u tin thit k nghin cu dch t hc xc nh yu t nguy c c th phng trnh c.

Tr li cu hi 205

2.8. Nhng t sut ny phn nh thc t l tui th trung bnh Cte dIvoire thp v khng c nhiu ngi thuc nhm cao tui (v nguy c ung th tng dn theo tui). 2.9. Khng th so snh hai nc nu khng c cc t sut chun ha theo tui. T sut th Nht Bn cao hn c th do tui th trung bnh y l cao nht v y cng c nhiu ngi cao tui hn Cte dIvoire ngha l phn b tui ca hai qun th khc hn nhau. Thc t, t sut ung th chun ha theo tui ca Nht Bn l 119,2 trn 100.000 so vi Cte dIvoire (ni c t sut l 160,2 trn 100.000 xem pha trn). Khi chun ha theo tui, t sut ca Cte dIvoire tng cn t sut ca Nht gim.

206 Ph lc

Chng 3
3.1. Cc thit k nghin cu dch t chnh l nghin cu ct ngang, nghin cu bnh chng, nghin cu thun tp v th nghim ngu nhin c i chng. im mnh v im yu ca cc thit k nghin cu ny c tm tt trong bi v trong Bng 3.3 v 3.4 3.2. Nghin cu bnh chng khi u vi cc ca bnh ung th i trng, nn l nhng ca mi chn on, v mt nhm cc trng hp chng (khng c bnh) t cng mt qun th ngun ( trnh sai s chn). Cc ca bnh v chng c hi v ch n thng ngy ca h trong qu kh. Sai s o lng c th l mt vn . Vic nh li ch n trong qu kh l tng i kh vi mc chnh xc cao, v s pht trin ca bnh c th nh hng n s nh li. S phn tch s so snh ni dung ca ch n trong cc nhm bnh v chng, kim sot theo cc bin s nhiu tim tng. Trong mt nghin cu thun tp, s liu chi tit v ch n c thu thp trong mt nhm ln ngi khng mc bnh i trng; nhm thun tp c theo di trong vi nm v tt c nhng ca bnh ung th i trng c xc nh. Nguy c mc bnh sau c lin h vi hm lng cht bo trong ch n ti thi im bt u nghin cu v trong sut qu trnh nghin cu. Loi thit k nghin cu ny th hin nhiu vn v hu cn nhng sai s h thng t l vn hn. 3.3. Sai s ngu nhin l s bin thin ca mt gi tr quan st t gi tr ca mt qun th thc ch do ngu nhin. Chng c th c gim bi vic tng kch c ca mu nghin cu v ci thin tin cy ca bin php o lng. 3.4. Sai s h thng xy ra khi c mt xu hng a ra cc kt qu khc mt cch h thng so vi cc gi tr thc. Cc ngun ch yu ca sai s h thng l sai s chn v sai s o lng. Sai s chn xy ra khi nhng ngi tham gia nghin cu khc mt khc h thng so vi nhng ngi khng tham gia. Kh nng sai s chn c th c gim bng mt nh ngha r rng v tiu ch la chn vo nghin cu, kin thc v lch s t nhin ca bnh v qun l bnh, v t l tham gia cao. Sai s o lng xy ra khi c mt sai s h thng trong o lng hoc phn loi cc thnh vin tham gia trong mt nghin cu. N c th c gim vi mt thit k nghin cu tt, v d, tiu ch chun cho bnh, ch chi tit n kim sot cht lng cc phng php o lng, v s thu thp s liu khi khng bit v tnh trng bnh ca ngi tham gia. 3.5. Nguy c tng i RR c s dng trong cc nghin cu tin cu (v d nghin cu thun tp) trong khi t s chnh OR c tnh trong mt nghin cu bnh chng (nghin cu hi cu). Trong mt nghin cu bnh chng, gm c nhng ngi c bnh v khng c bnh (bao gm nhng ngi phi nhim v khng phi nhim). V vy mi quan tm l vic tnh ton t s gia xc xut xut hin mt s kin v xc xut khng xut hin, xc nh kh nng mt ngi khng c bnh s mc bnh. Mt nguy c tng i hu nh khng bao gi c tnh ton trong cc nghin cu bnh chng. tnh nguy c tng i, cn so snh t l mi mc ca nhng ngi phi nhim v t l mi mc ca nhng ngi khng phi nhim (xc xut xut hin bnh trong nhm phi nhim v khng phi nhim).

Tr li cu hi 207

3.6. Xem tr li cu 3.5. Trong trng hp bnh him (v d nh hu ht cc loi ung th), RR v OR gn tng t nhau. l do cng thc tnh OR: (ngi bnh c phi nhim x ngi khng bnh khng phi nhim)/ (ngi bnh khng phi nhim x ngi khng bnh phi nhim). 3.7. Tui m l mt yu t nhiu: n lin quan n th t sinh v l mt yu t nguy c thm ch nu th t sinh l thp. Trong mt v d khc khi tt c cc b m di 30 tui, khng tm thy mi lin h vi th t sinh Th t sinh Tui m Mt cch trnh nhiu l phn tng theo tui ca m Hi chng Down

208 Ph lc

Chng 4
4.1. Tng s ca n=10 quan st l 679,1 kg; trung bnh l 67,91; trung v l 67,3 ch rng c hai quan st vi gi tr 67,3 c a vo gia nhm sau khi sp xp theo th t; phng sai l 104,03 kg2; lch chun l 10,20 kg; v sai s chun l 3,23 kg. 4.2. Trung v thng c s dng bo co thu nhp cho nhm v gi tr ny t b nhng mc thu nhp rt cao nh hng, yu t i khi c th lm tng ln ng k gi tr trung bnh, mc cao hn hu ht cc thnh vin khc ca nhm. 4.3. C hai khc bit ch yu trong cc m hnh ny. Th nht, mc d c ba c cc bin c lp ging nhau, nhng bin ph thuc li khc nhau, trong bin ph thuc ca hi quy tuyn tnh l bin lin tc, ca hi quy logic l bin nh phn nh tnh trng c hoc khng c mt c im no , v ca m hnh phn tch s sng l khong thi gian cho n khi mt s kin xy ra. H s cho hi quy tuyn tnh l khc bit gia cc trung bnh hay nghing, cho hi quy logic l t s chnh, v cho m hnh phn tch s sng l t s nguy c. 4.4. Cng hp cng tt. iu ny l chnh xc v khi nim khong tin cy ngha l, nh trung bnh mu, l c lng trung bnh ca qun th m mu ly t , l im gia ca khong tin cy. Ngoi ra, ta c th k vng 95% khong tin cy s cha gi tr thc ca trung bnh qun th, khong tin cy cng ngn, trung bnh mu cng gn vi trung bnh qun th. 4.5. Nhn chung, bng trnh by nhng s liu hay kt qu c th ng mt mnh trong bi bo hoc bo co. iu ny c ngha l ngi c c th phin gii nhng s liu trnh by m khng cn c cc din gii hoc cc ti liu khc. Tiu bng l yu t thit yu cho mc ch ny. S liu trong bng bao gm tp hp cc v tiu bng cn din gii ci g, phn loi nh th no, u v khi no nhng thng tin trong tng . V d S v t l phn trm nhng ngi tham gia, phn loi theo tui, chng tc v gii, nghin cu CARDIA, 2006. 4.6. Trong trng hp ny, b1=trung bnhnam trung bnhn = 5,0 kg, hiu chnh cho cc bin c lp khc trong m hnh. 4.7. Trong trng hp ny b1= 0,5 l nghing ca mi quan h gia tui v trng lng c th. H s ny l mc tng ln ca trng lng c th vi mi tui tng ln, c ngha l c tng thm mt tui, trong lng c th tng thm 0,5 kg.

Tr li cu hi 209

Chng 5
5.1. Qu trnh xc nh xem s kt hp quan st liu c phi l mi quan h cn nhn. 5.2. iu ny c ngha l mt s yu t cn nguyn dn n tnh trng phi nhim vi mt s yu t khc l nguyn nhn trc tip ca bnh. V d, thu nhp thp lin quan n tnh trng t s dng hoa qu v rau xanh Vng quc Anh (Hnh 5.9). t s dng hoa qu v rau xanh li lin quan n tnh trng huyt p tm trng cao. Thu nhp quyt nh dinh dng, yu t quyt nh mt tnh trng sc khe, h th bc cc nguyn nhn. 5.3. Cc phn s quy thuc nh sau: ht thuc trong s nhng cng nhn phi nhim aming = (60258)/602 = 0,904, hay 90%; ht thuc trong s nhng cng nhn khng phi nhim aming = (12311)/123 = 0,910 hay 91%; phi nhim aming trong s nhng cng nhn ht thuc = 602123)/602 = 0,796 hay 80%; phi nhim aming trong s nhng cng nhn khng ht thuc = (5811)/56 = 0,810 hay 81%. Nhng phn s ny cng li ln hn 100% v chng ph thuc ln nhau. V vy, loi b ht thuc l nhng cng nhn phi nhim vi aming gim 90% ung th phi, v khi loi b phi nhim aming gim 80% nguy c cn li. Tng lng gim nguy c l 90% + 80% x 0,1, tng ng vi gim 98%. Khi quyt nh chng trnh phng chng, phn quyt cn da vo ln t l m mt phi nhim c th loi b. Thay i v cng ngh c th loi b ton b phi nhim vi aming, trong khi chng trnh cm ht thuc ch c th loi b c mt phn ca tnh trng phi nhim vi thuc l. tnh c nguy c quy thuc qun th, cn phi bit t l ht thuc v t l phi nhim vi aming ti ni lm vin trong qun th. 5.4. Tiu ch bao gm: mi quan h thi gian, tnh hp l, tnh nht qun, mnh ca s kt hp, mi quan h liu p ng, tnh thun nghch, v thit k nghin cu. Trong s nhng tiu ch ny, ch c mi quan h thi gian l thit yu, cui cng l phn quyt. 5.5. Ch trn c s bng chng ny th khng xc nh s kt hp l cn nguyn; v th, khng th khuyn co chnh sch thu hi loi thuc ny. Cn nh gi tc ng ca cc loi sai s (o lng, chn) v nhiu trong nghin cu v vai tr ca may ri. Nu sai s v may ri khng phi l li l gii, s cn p dng cc tiu ch cn nguyn. Thc t, khi tt c bng chng c xem xt trong nghin cu New Zealand, cc nh iu tra kt lun rng nhiu kh nng s kt hp ny l cn nguyn. 5.6. Mi quan h thi gian l quan trng nht. Bnh nhn s dng du n trc hay sau khi h b bnh. Bng chng trc y v c tnh c th ca loi ha cht ny cng rt quan trng. Nu khng c thng tin no v thnh phn ha cht trong du n c lin quan n bnh, s cn nh gi tnh hp l hay tnh nht qun. Vi th mnh v mi quan h liu p ng da trn thng tin v s dng du n s l vn cn xem xt tip theo trong nghin cu. V y l vn u tin khn cp tm nguyn nhn c th, cch tip cn ph hp nht l tin hnh mt nghin cu bnh chng, cng vi vic phn tch ha hc v theo di sinh hc. Mt im quan trng l tin hnh can thip cng sm cng tt khi mi quan h thi gian c xc nh v mnh s kt hp l ln, c bit l khi khng c nguyn nhn kh nng no khc.

210 Ph lc 5.7. C th chp nhn nhng tc ng cp tnh xy ra trong vng vi gi hoc vi ngy sau khi phi nhim. Khi c th s dng nhm phi nhim cng l nhm i chng. Qun th phi nhim trong nhng ngy nng v cng chnh qun th trong nhng ngy mt l i chng. Nu s dng s liu hng ngy, c th nh gi rng kch thc v c im qun th khng i trong thi gian nghin cu v c th hn ch nhiu. 5.8. Phn tch tng hp kt hp s liu ca nhiu nghin cu tp hp c nhiu kt lun n nh v chnh xc hn lin quan n s kt hp cn nguyn. s dng c phng php ny, mi nghin cu cn phi s dng cng phi nhim v tnh trng sc khe, v cc c im qun th c bn khc (tui, gii, ) cng tng ng vi nhau trong cc nghin cu. 5.9. Nguy c thiu mu tim cc b nhm ng phn v thp hn v tnh trng s dng hoa qu v rau xanh cao gp hai ln nhm ng phn v cao hn (Hnh 5.8). Mc s dng hoa qu v rau xanh trong hnh 5.9 nhm ng phn v cao nht v thp nht tng ng l khong 300 v 150 gram trong mt ngy. Tng hp nhng s liu ny cho thy nhm thu nhp thp hn c nguy c thiu mu tim cc b gp bn ln so vi nhm thu nhp cao hn, trong mi lin h vi mc s dng hoa qu v rau xanh. R rng, nhng hnh ng v chnh sch y t cng cng s cn tm cch vic s dng hoa qu v rau xanh tr nn ph bin hn nhm h gia nh c thu nhp thp. Hnh 5.9 cho thy t nht l Vng quc Anh, gi c thc phm l mt yu t quan trng. iu ny cng ging nh cc loi thu p dng cho cc sn phm c hi cho sc khe nh thuc l, c th p dng cc khon h tr cho vic sn xut v phn phi hoa qu v rau xanh. Cc ba n tra ti trng hc cng c th l mt mc tiu nhm ci thin ch dinh dng.

Tr li cu hi 211

Chng 6
6.1. Bn cp d phng l: d phng cp 0 (cn nguyn), cp I, cp II v cp III. Mt chng trnh d phng ton din bnh t qu s bao gm cc hot ng ti mi cp trn. D phng cp 0 lin quan n vic ngng gia tng cc mc qun th ca cc yu t nguy c chnh ca cc bnh mn tnh ph bin bao gm t qu. D phng cp I bao gm d phng qun th thng qua lut y t cng cng v cc thay i mi trng ton qun th, cng nh mt chin lc nguy c cao nhm n iu tr cc c th c nguy c cao mc bnh t qu cp tnh. Cc chng trnh d phng cp II lin quan n iu tr sm v phc hi chc nng. Nu nhng ngi b cn au tim hoc t qu c bao gm trong chin lc d phng nguy c cao, trn thc t, iu ny kt hp chin lc nguy c cao vi d phng cp II. D phng cp ba lin quan n phc hi chc nng nhng bnh nhn b tc ng lu di ca t qu 6.2. iu ny khng th tr li c v mt thut ng chung. Mi chng trnh d phng tim nng cn c nh gi trong hon cnh. Mi chng trnh cn cn bng bi mt s kt hp ph hp ca qun th v cc hot ng nguy c cao da trn mt s cc yu t bao gm cc mc ca i tho ng v bo ph, cc yu t nguy c chnh, v s chi tr c ca chm sc lm sng, v cc vn cng bng. Th thch khng phi l la chn gia mt cch tip cn vi mt cch khc, nhng chuyn s u t sang cc cch tip cn qun th trong khi ci thin cht lng ca cc cch tip cn nguy c cao hin ang s dng. 6.3. mt bnh thch hp cho sng tuyn, cn phi l bnh trm trng, lch s t nhin ca bnh c bit, cn c khong thi gian di t khi c cc du hiu u tin n khi xut hin bnh ton pht, cn sn c bin php iu tr hiu qu v thng l t l hin mc ca bnh phi cao. 6.4. Tt c cc thit k nghin cu ang c s dng nh gi cc chng trnh sng tuyn. Cc th nghim ngu nhin c i chng l l tng, nhng nghin cu ct ngang, thun tp v bnh chng cng c s dng.

212 Ph lc

Chng 7
7.1. Brazil, t l t vong do cc bnh truyn nhim gim dn t nm 1950 v do cc bnh mn tnh ang ngy tr nn ng k. Nhng thay i v dn s, trong c t l ngi cao tui tng ln, l mt l gii. S hu ch hn nu c s liu t vong theo tui cho tng loi bnh c th c th nh gi chi tit xu hng ny. C th c hai l gii cho tnh trng gim xung v t l t vong theo tui ca cc bnh truyn nhim. Th nht, vt ch cm nhim gim xung do tnh trng dinh dng v v sinh c ci thin. Th hai, nhng can thip y hc cng ng gp mt phn, nht l t nhng nm 1950. 7.2. Cn phi lu gi nhng h s hng tun (hoc hng ngy) nhng trng hp si ti cc phng khm hoc phng mch ca bc s trong huyn. Cn xc nh mc nn bnh thng (c th l hai hoc t hn trng hp mt tun) v mc ngng nghi ng du hiu ca dch (c th gp hai hoc ba ln mc nn). Khi vt qua ngng, phi thc hin cc hnh ng phng chng. 7.3. ng ly nhim ca salmonella thc phm xut pht t phn (c th t ngi hoc ng vt, c bit l g) n nc hoc thc phm ri c s dng, dn n nhim bnh. Ngoi ra, ng ly truyn c th xut pht t phn n tay v sau n thc phm (trong qu trnh ch bin thc phm), dn n nhim bnh. 7.4. Quy nh sc khe quc t sa i (2005) (International Health Regulation IHR) hnh thnh mt m cc th tc v thc hnh cho cc bin php y t cng cng duy nht. IHR (2005) khng bao gm c ch thi hnh cho nhng quc gia khng chp hnh quy nh ny. Cc nc s cn m ng c cc yu cu v nhn lc v ti chnh Xy dng, tng cng v duy tr nng lc y t cng cng cn thit, v huy ng nhng ngun lc cn thit cho mc tiu ny; Thc thi cc quy nh lut php v hnh chnh cn thit; Ch nh mt im u mi IHR quc gia; nh gi v thng bo nhng s kin xy ra trn phm vi lnh th m c th dn n nhng tnh hung y t cng cng khn cp lin quan n quc t v; Trin khai nhng bin php mt s sn bay, cng bin v ng bin gii quc t, bao gm cc hot ng kim tra v gim st thng xuyn.

7.5. Bn cp d phng l: cn nguyn, cp mt, cp hai v cp ba. Mt chng trnh phng chng lao ton din cn bao gm hot ng cho cc cp d phng. D phng cn nguyn c th lin quan n phng chng s gia nhp ca cc trng hp bnh vo qun th khe mnh. Ngi nhng vng dch lu hnh c yu cu cung cp bng chng rng h khng b bnh trc khi c php gia nhp vo vng khng c dch lu hnh. Ngoi ra, cng cn gii quyt cc yu t lm tng nguy c bnh lao nh qu ng c, ngho i v thiu dinh dng. D phng cp mt bao gm tim phng v xc nh ca bnh trnh ly lan bnh. D phng cp hai lin quan n vic iu tr sm v hiu qu nhng ngi b bnh. D phng cp ba lin quan n phc hi chc nng cho nhng ngi b bnh trnh nhng tc ng lu di do lao v qu trnh iu tr.

Tr li cu hi 213

Chng 8

Tr li cu hi
8.1. Thut ng hon ton i lp ch dch t hc gii quyt vi cc qun th trong khi y hc lm sng gii quyt vi cc bnh nhn c th. Tuy nhin, iu ny l ph hp v dch t hc lm sng nghin cu cc qun th bnh nhn. 8.2. Hn ch ca nh ngha ny l khng c c s sinh hc cho vic s dng im ct ch quan lm nn tng cho s phn bit bnh thng vi bt thng. Vi rt nhiu bnh, nguy c mc bnh tng cng vi s tng cc yu t nguy c v v rt nhiu dnh nng bnh tt ri vo nhng ngi trong gii hn bnh thng. 8.3. nhy ca xt nghim mi = 8/10 x 100 = 80%; v c hiu = 9.000/10.000 x 100 = 90%. Xt nghim mi c v tt; quyt nh c nn s dng cho qun th chung cn c thng tin v gi tr d on dng tnh, trong trng hp ny l 8/1.008 = 0,0008. Gi tr rt thp ny c lin quan n hin mc thp ca bnh. V l do ny, khng nn s dng xt nghim ny cho qun th chung. 8.4. Gi tr d on dng tnh l t l nhng ngi c kt qu dng tnh c mc bnh thc s. Yu t quyt nh chnh ca gi tr d on dng tnh l t l hin mc bnh tin lm sng trong qun th c sng tuyn. Nu qun th mc nguy c mc bnh thp, hu ht cc kt qu dng tnh l sai. Gi tr d on cng ph thuc vo nhy v c hiu ca xt nghim sng tuyn. 8.5. Mt s cc vn tim tng trong phn tch tng hp ny bao gm: Liu aspirin, thi gian iu tr, thi gian theo di khng thng nht trong 6 nghin cu c la chn Thm ch vi 6 th nghim ln tng hp li, s lng cc c th mc bnh khng ln bi v nguy c thp ca qun th nghin cu, v vy lm gim hiu lc ca nghin cu trong pht hin s khc bit. Ch phn tch cc s liu t cc i tng ca ton b cc th nghim sn c cho php kim tra li ch ca aspirin trong cc nhm nh c bit, nhng ngi c th c c li ch. Phn tch tng hp l nghin cu hi cu, tu thuc vo cc im yu trong mi nghin cu c la chn vo. 8.6. Da trn c s ca nghin cu ny, c th kt lun rng aspirin liu thp lin quan n s gim cc bnh tim mch c nam v n nhng cng lin quan n mt nguy c ca chy mu. Cc khuyn ngh cn bao gm nhu cu gii thch cho mt bnh nhn c nhng tc ng c li v c hi ca aspirin trc khi xem xt aspirin cho d phng cp I bnh tim mch trn nhng bnh nhn nguy c thp. Thng tin ny cn c truyn t theo mt cch c ngha v lm sng v kha cnh s lng cn c iu tr (v s lng cn ) hoc s gim nguy c tuyt i hn l gim nguy c tng i.

214 Ph lc

Chng 9
9.1. (a) Tr em, do tc ng xut hin tr em khi mc trong mu thp hn (b) Bin i chc nng thn kinh hnh vi, do tc ng ny xut hin mc trong mu thp hn. 9.2. (a) Nguy c tng i ung th phi tng ln (b) Do tng lng (liu) ht (si) aming ht phi (nng x thi gian phi nhim) l yu t xc nh nguy c xut hin bnh do aming. 9.3. Cu tr li ph thuc vo loi cht c la chn. Loi cht liu sinh hc c th xem xt l: mu, nc tiu, tc, nc bt, mng tay, phn, v c th l sinh thit. 9.4. C th bt u bng tp hp nhng trng hp trong qu kh, trao i vi dch v y t a phng, tham quan cc c s cng nghip nghi ng xy dng gi thuyt nghin cu. Sau c th tin hnh mt nghin cu bnh chng v ung th phi trong thnh ph. 9.5. S liu t vong ca nhng nm trc (khng c khi) v nguyn nhn t vong theo tui c th c ch. Bng chng t cc th nghim trn sc vt c th cho bit tc ng do khi (thc t, nhng sc vt bn ch Smith Field London cng b nh hng). Mi lin quan gia khi v nhng cht nhim vi nguy c t vong tng cao l nhng bng chng c th v mi quan h cn nguyn. 9.6. Tc ng cng nhn khe mnh l tnh trng t l t vong v bnh tt thp c nhm c v khng c phi nhim nhng ni lm vic. Nguyn nhn l do c th lm vic, ngi cng nhn phi sc khe. Nhng ngi b m hoc tn tt b loi khi nhm nghin cu. Nu nhm chng c chn t qun th chung, sai lch s xut hin do nhm ny s khng khe mnh nh nhm cng nhn. 9.7. nhng ni: a. C sn s liu bin gii a l v thng k dn s; b. C th o lng c phi nhim quan tm cng khu vc a l; c. S liu phi nhim v tc ng cho tng vng a l c th c tp hp trong khong thi gian ph hp. 9.8. Li xe t hoc xe my: dy bo him, gii hn tc , gii hn nng ru, m bo him. Thit k nh v ni lm vic. Cc c im an ton ca cc sn phm gia dng, nh in, np lo thuc an ton vi tr em, o phao trn thuyn

Tr li cu hi 215

Chng 10
10.1. S dng nhng nguyn l hng dn ca Hin chng Bangkok hng ti vic pht trin chnh sch cng c th bao gm cc hnh ng sau: Bin minh: S bin minh l cn thit nhm m bo nh nc phi thc hin cc cam kt, rng buc trong Hip nh khung v kim sot thuc l nhm phng ht thuc l tr em. u t: Ngun lc nhm vo cc yu t quyt nh c bn lin quan n s dng thuc l tr v d., s mt mt, ngho i v s ght b. Xy dng nng lc: m bo rng nng lc con ngi trin khai chng trnh v cc ngun lc ti chnh. iu hnh v thc thi lut: Tr em cn phi c bo v khi cc hot ng qung co, khuyn mi ca tt c cc sn phm thuc l. Xy dng lin minh: Nh nc v x hi dn s cn phi lin kt lc lng trin khai cc hnh ng cn thit. 10.2. Cc cu hi khc nhau cn c hi tng giai on ca chu trnh qun l: nh gi gnh nng bnh tt Tn sut ng ca ngi gi nh th no? Cc s liu dch t hc g c sn? Nghin cu g cn tin hnh? Xc nh nguyn nhn Ng c th c phng nga bng cch no? Cc hot ng theo di v o lng tin (v d. ch s o lng) Can thip hiu qu Cc ngun lc iu tr no c sn? Xc nh hiu sut Cc dch v iu tr c hiu qu nh th no? Cc dch v g c dnh cho phc hi chc nng v hiu qu nh th no? Chi ph ca cc dch v ny c so snh nh th no vi hiu qu cc dch v ny em li? Trin khai can thip Loi dch v mi c cn c thit lp v kim nh (tested) hay khng? nh gi S xut hin ca cc trng hp ng c thay i khng k t khi dch v mi c cung cp? 10.3. Nhng thng s sau y cn cn nhc khi xy dng chnh sch cp quc gia Gnh nng bnh tt: Xt v cc kha cnh mc bnh v t vong, bnh khng truyn nhim c c coi l u tin hay khng? S liu quc gia c mc tin cy th no? Cc bnh khng truyn nhim no c cho l cc bnh u tin? Cn nguyn: C bng chng ti a phng v tm quan trng cn nguyn ca cc yu t nguy c ph bin? C cn bng chng ny khng? Hiu qu: C cc bng chng no lin quan n tnh hiu qu v chi ph hiu qu ca cc can thip chun lin quan n bnh truyn nhim i vi c hai cp l c th v qun th?

216 Ph lc Hiu sut: Chnh sch lin quan n bnh khng truyn nhim c phi l cch tt nht s dng ngun lc hin c? Trin khai: Cc u tin cho vic trin khai cp c th v qun th l g? Theo di v o lng tin : C hot ng theo di v nh gi c tin hnh hay khng? Cc u tin ca vic nh gi l g?

Tr li cu hi 217

Chng 11
11.1. y l mt nghin cu thc nghim lm sng phn b ngu nhin c i chng v s dng thuc aspirin trong d phng t vong tim mch c thit k v trin khai nghin cu tt. nghin cu c tin hnh trn i tng l cc phu thut vin nam, li l nhng ngi c sc khe tt. c 22,000 trn tng s 261,000 phu thut vin tham gia vo nghin cu. Tnh trng sc khe tt ca i tng lm cho nghin cu t c ngha thng k so vi k hoch. Vic suy rng kt lun ca nghin cu cho cc nhm i tng khc l kh khn do vic loi tr gii hn qun th nghin cu trong nhm phu thut vin v khng c cc tc dng ph. c im ny lm tng t l thnh cng. Vic khng nh li kt lun v li ch ca aspirin cn c thc hin trong cc nghin cu khc. iu cn thit l lun phi cn bng gia li ch v cc nguy c (tc dng ph vi d dy, tng nguy c xut huyt) 12.1. Cc bng chng sinh thi hc cho thy mi lin quan ca phng php iu tr hen suyn vi t vong do bnh hen suyn. Chng ta kh c th ng vi kt lun ny. Do nghin cu ch th hin thng tin ca cc trng hp hen suyn sp t vong (dying asthma) m khng c thng tin v nhng trng hp hen suyn bnh thng. Nghin cu ny l chui cc trng hp bnh: khng c nhm chng. Tuy nhin, nhng nghin cu nh vy cho thy nhu cu cn c nhng nghin cu trong tng lai. Trong trng hp ny, c mt iu tra chnh quy hn v xu hng t vong do hen suyn nhn nh c mt t t vong do hen suyn mi xut hin m nguyn nhn vn cha c xc nh, cho d dng nh c thuc c tr cho cn bnh ny.