Professional Documents
Culture Documents
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
Tp ch ca Hi y khoa Thu in
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.
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
Thng ip chnh.................................................................................................1
Ngun gc ..............................................................................................1
nh ngha ..............................................................................................3
Phm vi...................................................................................................3
nh gi can thip..................................................................................6
u ma .................................................................................................7
HIV/AIDS ..............................................................................................12
SARS....................................................................................................13
Cu hi ..............................................................................................................13
Thng ip chnh...............................................................................................17
nh ngha ............................................................................................17
Hin mc v mi mc...........................................................................19
T l cht mc ...................................................................................23
T vong ................................................................................................25
T sut t vong..................................................................................................27
Tn tt ..................................................................................................33
Cu hi ..............................................................................................................38
Thng ip chnh...............................................................................................41
Cc nghin cu m t .........................................................................42
C mu.................................................................................................56
Sai s h thng.....................................................................................56
Nhiu .................................................................................................................58
Tnh gi tr.............................................................................................60
vi Mc lc
Vn o c ....................................................................................61
Cu hi ..............................................................................................................63
Thng ip chnh...............................................................................................67
Tng hp s liu................................................................................................67
Cc bn v th..................................................................................68
Bn chm v bn t l................................................................69
th hnh ct ......................................................................................70
th hnh dy .....................................................................................71
Gi tr p .................................................................................................76
Lc thng k.........................................................................................76
Kim nh t............................................................................................78
Tng quan..........................................................................................79
Hi quy .................................................................................................80
Cc vn c mu ..............................................................................85
Cu hi ..............................................................................................................87
Thng ip chnh...............................................................................................89
v cn .............................................................................................90
C ch gy bnh .................................................................................91
Cc yu t ca nguyn nhn................................................................92
Tng tc.............................................................................................93
Tnh hp l ...........................................................................................96
mnh ca s kt hp......................................................................99
nh gi bng chng........................................................................102
Cu hi ..........................................................................................................103
Thng ip chnh............................................................................................107
D phng cp I...............................................................................................114
D phng cp II..............................................................................................117
D phng cp ba............................................................................................118
nh ngha .........................................................................................119
Cu hi ..........................................................................................................123
Thng ip chnh............................................................................................127
nh ngha .........................................................................................127
Dch ...................................................................................................130
Mc lc ix
Ly truyn..........................................................................................135
Vt ch ..............................................................................................136
Mi trng.........................................................................................137
iu tra ..............................................................................................137
Xc nh cc ca bnh .......................................................................137
Cu hi ...........................................................................................................142
Thng ip chnh............................................................................................145
S bt thng kt hp vi bnh.......................................................147
Bt thng c th iu tr c ........................................................147
Gi tr ca mt xt nghim ................................................................148
Hiu qu iu tr .............................................................................................151
x Mc lc
Cu hi ..........................................................................................................155
Thng ip chnh............................................................................................157
nh gi nguy c ..............................................................................167
nh gi tc ng sc khe .............................................................167
nh gi tc ng sc khe mi trng...........................................168
Bo lc ..............................................................................................171
Mc lc xi
T t..................................................................................................171
Cu hi ..........................................................................................................173
Thng ip chnh............................................................................................177
Lp k hoch y t ..............................................................................177
nh gi ............................................................................................178
Cu hi ..........................................................................................................189
Thng ip chnh............................................................................................191
Cc bnh c th ...........................................................................................191
c c ph phn ............................................................................................192
Chun b ng ti ..............................................................................198
c thm ........................................................................................................198
Tip tc o to..............................................................................................200
Cu hi ..........................................................................................................201
Tm tt ..............................................................................................202
Ph lc Tr li cu hi...................................................................................203
Mc lc xiii
Li ni u
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.
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.
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
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).
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).
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.
4 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
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 7
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
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
8 Chng 1
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).
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
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.
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
C Khng 58
Khng C 123
C C 602
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.
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
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).
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
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
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
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.
a
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
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).
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
Mi mc Hin mc
T s S trng hp bnh mi trong mt S trng hp ang mc bnh vo
khong thi gian xc nh mt thi im
Mu s Qun th nguy c Qun th nguy c
Trng tm Trng hp bnh l mi hay c S c tn ti hay khng tn ti ca
Thi im bnh xut hin bnh
Khong thi gian l tu , thay v mt
khonh khc thi gian
S dng Th hin nguy c nhim bnh c lng xc sut ca qun th
L o lng chnh ca nhng bnh ang mc bnh trong khong thi
hoc tnh trng cp tnh, nhng cng gian nghin cu
c s dng cho c nhng bnh Hu ch trong nghin cu gnh nng
mn tnh ca cc bnh mn tnh v l c s
Hu ch hn cho nhng nghin cu cho dch v y t
xc nh nguyn nhn
Hin mc (prevalence)
T l hin mc (P) mt bnh c tnh theo cng thc sau:
S trng hp c bnh hay mt tnh trng trong mt thi im hay mt
khong thi gian
P = 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.
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.
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.
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 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.
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.
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.
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:
S trng hp t vong trong mt khong thi gian xc nh
T sut t vong th = (x 10n)
Trung bnh tng qun th trong khong thi gian
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.
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.
22
Hnh 2.4. Xu hng t sut t vong s sinh ton cu 1950-2000
Nc T sut t vong tr em
(trn 1000 tr sinh sng)
Nam N
Cc nc thu nhp cao
Nht bn 4 4
Php 5 5
Canada 6 5
M 9 7
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
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:
S t vong c lin quan n thai sn ca b m trong 1 nm
MMR = (x 10n)
Tng s tr sinh trong cng nm
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.
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.
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 .
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.
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
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.
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
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.
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
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.
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.
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.
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
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.
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).
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
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.
Cc nghin cu quan st
Cc nghin cu m t
Cc nghin cu phn tch
Sinh thi Tng quan Cc qun th
Ct ngang Hin mc Cc c th
Bnh chng Bnh tham chiu Cc c th
Thun tp Theo di Cc c th
Cc nghin cu thc nghim Cc nghin cu can thip
Cc th nghim ngu nhin c i chng Cc th nghim lm sng Cc c th
Cc th nghim cm ngu nhin c i chng Cc nhm
Th nghim thc a
Th nghim cng ng Ngi kho
Nghin cu can thip ti Cng ng
cng ng
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.
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.
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.
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.
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
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).
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
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:
50 41
OR = (50 / 11) (16 / 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.
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.
Thi gian
Hng iu tra
Bnh
PhI nhim
Khng bnh
Ngi khng
Qun th
nhim bnh
Bnh
Khng bnh
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).
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).
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.
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
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).
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
Hnh 3.9. M hnh th nghim phn b ngu nhin cng ng vo nhm can
thip v nhm chng21
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.
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.
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.
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).
Hnh 3.10. Nhiu: ung c ph, ht thuc l v bnh mch vnh tim
Cc thit k nghin cu 59
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.
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
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
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
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.
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
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 Hy cho bit cc ng dng v nhng nhc im ca cc thit k nghin
cu dch t chnh?
3.2 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?
3.3 Sai s ngu nhin l g v lm th no gim nh hng?
3.4 Cc loi sai s h thng chnh trong cc nghin cu dch t l g v lm th
no gim tc ng ca chng?
3.5 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.
3.6 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
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.
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.
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.
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
Bn chm v bn t l
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
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.
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.
n
Trung bnh = x = x
i =1
i /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.
s 2
=
x 2
() 2 / n
n 1
T s ca cng thc trn c th c vit di dng:
SS ( x) ( x x ) 2 = x 2 ( x) / n
2
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.
= trung bnh
= lch chun
= h s hi qui
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.
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).
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
x
t=
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:
69.7 80
t= = 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
Thc t
Kt qu kim nh
H0 ng H0 sai
Chp thun H0 NG Sai s loi II hoc sai s
Loi b H0 Sai s loi I hoc sai s NG
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
Tng quan
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 =
SS ( xy)
[ x ( x) / n ][ y ( y )
2 2 2 2
/ n] SS ( x) SS ( y )
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.
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
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 :
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:
SS (M hnh)
R2 =
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 Nhm mu x1 x2
vic phin gii ng l rt quan trng. V d v
phn loi ca nhm mu vi ba nhm mu l A, A 1 0
B, v O. Vi thc t ny, chng ta cn c hai B 0 1
bin c lp - nh hn s phn loi l mt. Trong
trng hp ny, nhm tham chiu l phn loi O 0 0
O v nhng gi tr ca cc bin l:
1 = A - O
2 = B - O
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.
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.
Chnh = p/(1-p)
Nh vy m hnh s tr thnh:
e1 = ORNam/N
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.
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:
Trong :
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
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:
ng cong Kaplan-Meier
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
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)
4 2 ( Z 0,975 + Z 1 ) 2
N = n1 + n 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:
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.
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 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.
4.2 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?
4.3 Nhng khc bit c bn gia hi quy tuyn tnh, hi quy logic, v cc m
hnh hi qui cho phn tch s sng?
4.4 Khong tin cy rng hay khong tin cy hp c gi tr hn trong phin gii
s liu, ti sao?
4.5 Nhng thng tin no cn c trong tiu ca bng trnh by s liu hoc
kt qu?
4.6 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?
4.7 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
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).
Cc yu t Xm nhp
Phi nhim vi vi khun
di truyn vo m
Vt ch Bnh
Nhim bnh
cm nhim lao
Nh cht chi
Ngho i
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
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.
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.
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 .
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
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
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
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
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.
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.
Bng 5.2: T l phn trm ngi b khim thnh lin quan phi nhim vi ting
n ni lm vic 24
Mi quan h liu - p ng
400 30
25
20
200 15
10
100
5
0 0
1 2 3 4 5 6 7 8 9 10
Thp phn v theo mc thu nhp ca gia nh trn u ngi (1=thp nht,
10=cao nht)
Mc tiu th (gam/ngi/ngy) Thu nhp chi cho thc phm
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 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
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
Cu hi
5.1. Th no l suy lun cn nguyn?
5.2. 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
5.3. 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.
5.4. Lit k cc tiu chun thng dng nh gi bn cht nguyn nhn ca
cc s kt hp quan st c.
5.5. 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 ?
5.6. 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?
5.7. 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?
5.8. Th no l phn tch tng hp v cn c nhng u kin g p dng
phng php ny.
5.9. 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.
104 Chng 5
20. Little J, Cardy A, Munger RG. Tobacco smoking and oral clefts: a meta-
analysis. 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.
Hnh 6.1 trnh by t l t vong do bnh lao ti Anh v Wales trong giai on 1840-
1968 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.
Hnh 6.1. T l t vong chun ho theo tui do bnh lao Anh v Wale, 1840-
19681
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)
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
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.
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.
Hnh 6.5. Mi lin h ngc gia gi thc ca thuc l v tiu th thuc l, Nam
Phi, 1961-20013
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
Hnh 6.6.
16 50
14 40
12 30
10 20
8 10
6 0
160 190 220 250 280 310 340 370 mg/dl
5 6 7 8 9 mmol/l
Dch t hc v phng nga cc bnh khng ly nhim 115
Hnh 6.7. Phn b tng cholesterol (mmol/l) ti ba qun th: A (Thp), B (Trung
bnh), C(cao).21
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.
Nhc im
Li ch thp i vi c nhn Kh khn trong vic xc nh nhng c th
c nguy c cao
Thiu khuyn khch ch th
Hiu qu tm thi
Thiu khuyn khch cc nh lm
sng Hiu qu hn ch
T s li ch-nguy c thp Khng thch hp trn kha cnh hnh vi
Dch t hc v phng nga cc bnh khng ly nhim 117
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.
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
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.
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
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.
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).
Bnh c xc nh r
T l hin mc bit
Lch s bnh 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
La chn xt nghim n gin v an ton
Gi tr xt nghim S phn b cc gi tr ca xt nghim trn cc c th b nh hng
v khng b nh hng bit
Ti chnh Chi ph hiu qu
Cc phng tin Sn c v d cung cp
Tnh chp nhn 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.
Tnh cng bng 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.
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 ph-
hiu 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.
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).
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 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.
6.2 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?
6.3 Cc c tnh no ca mt bnh cho bit bnh ph hp vi sng tuyn?
6.4 Cc thit k nghin cu dch t no c th c s dng nh gi mt
chng trnh sng tuyn?
124 Chng 6
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::AID-
CNCR2820631002>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 non-
10.1258/0969141053279086
127
Chng 7
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
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.
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
Chn thng
9% Ung th
13%
Cc bnh
mn tnh khc Bnh tiu Cc bnh h
9% ng hp mn tnh
2% 7%
Cc bnh truyn nhim: gim st dch t hc v phn hi 129
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)
Cc bnh mn
tnh khc, bao
gm ri lon
Chn thng tm thn
13% 28%
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.
100
80
60
40
20
73 74 75 76 77 78 79 80 81 82
Nm
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
A B
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).
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:
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.
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:
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.
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
Cc bnh truyn nhim: gim st dch t hc v phn hi 135
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.
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).
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.
tc nhn gy bnh truyn nhim sng nhng bin i (nh vc xin cho bnh
si)
Cc bnh truyn nhim: gim st dch t hc v phn hi 137
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 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
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)
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.
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).
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.
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.
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
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 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).
Cu hi
7.1. 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?
7.2. 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?
7.3. Bn hy m t dy chuyn ly bnh cho v ng c thc n do salmonella.
7.4. Hy bnh lun nhng tr ngi c th nh hng n tnh hiu qu ca Cc
Quy nh Sc khe quc t sa i.
7.5. 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
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.
2
4
1 2
0.50
0.50
0.25 0.25
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.
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.
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.
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
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.
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
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.
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.
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
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.
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
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
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).
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:
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.
Yu t V d
Tm l Stress, tht nghip, lm ca, mi quan h
Sinh hc Vi khun, vi rt, sinh vt k sinh
Mi trng bn ngoi Kh hu, ting n, bc x, ergonomics (iu kin, t th lm vic)
Tai nn Tnh hung bt ng, tc , tc dng ca ru, ma ty
Ha cht Thuc l, ha cht, bi, cht kch thch d ng da, cht ph gia trong thc phm
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.
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).
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 9.3: 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.
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
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
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.
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
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.
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.
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.
Hp 9.3: V d: nh gi tc ng sc khe
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.
Nguyn nhn
Lch s t nhin
Tnh trng sc khe ca qun th
Gi tr ca can thip v dch v y t
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.
Cu hi
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
177
Chng 10
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
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).
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
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 10.3. Tin trnh ca vic hnh thnh chnh sch quc gia lin quan
n bnh mch vnh.
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.
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.
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
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
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.
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.
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
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
Thc hin Chng trnh quc gia v kim sot cao huyt p
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.
Cu hi
10.1. 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.
10.2. 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.
10.3. 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
Chng 11
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.
Cn nguyn bnh:
Cc yu t cn nguyn c th
Cc yu t nguy c khc
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
ng lc thc y V d
chnh sch lut qung co thuc l
kinh t thu nh vo thuc l, lm gi thuc l
pht trin cng ngh my xc tc lm gim nhim khng kh
Ngun tc hi
cc qui trnh c th t than v nhim khng kh
tc ng ca cc yu t khc cc yu t thu vn v nhim khng kh
bin i theo ngy v theo ma cc mc zn
xu hng lch s v a l
Yu t tc ng n mc phi nhim nh hng sc khe
ln con ngi
tui, gii, s khc bit v chng tc C ch nguyn nhn
ch n, hot ng th lc Nhng du hiu ha sinh hoc sinh l v nh
yu t thi tit hng
hot ng cng vic Bin pht phng phi nhim v nh
hng sc khe
Cc yu t hnh vi khc
Cu hi nghin cu l g ?
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.
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?
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
Nu l m tnghin cu quan st
nh gi cui cng
Cc cu hi di y c th c hi cn nhc cc bng chng
Bng 11.3. Hng dn thng nht v cch thc xy dng thit k nghin cu
v vit bo co
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.
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
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 11.5 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.
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
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).
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.
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.
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.
2.3. 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%.
2.5. 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.
2.8. 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).
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
Tui m
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.
4.4. 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.
4.6. 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.
5.3. 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.
5.6. 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
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
6.3. 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.
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.
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.
8.6. 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.
9.5. 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.
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.
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)
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?
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.