家长医患沟通效能对孤独症谱系障碍儿童康复效果的影响

doi:10.3969/j.issn.1006-9771.2024.05.012

Abstract

Abstract:

Objective To explore the potential influencing factors and complex pathways affecting rehabilitation effect for children with autism spectrum disorder (ASD) from the perspective of parental efficacy in doctor-patient communication, and to provide evidence for improving the quality of rehabilitation service for children with ASD.

Methods An anonymous face-to-face questionnaire survey was conducted to collect general demographic information of parents of children with ASD at designated rehabilitation institutions in Gansu province. The data included parental efficacy in doctor-patient communication, parental compliance of treatment and children's rehabilitation outcomes were collected. A structural equation model was used to explore the impact mechanism of parental communication efficacy on the rehabilitation outcomes of children with ASD.

Results Data from 519 parents at 37 rehabilitation institutions across 13 cities/counties in Gansu province were collected. Significant positive correlations were found between parental efficacy in doctor-patient communication, doctor-patient relationships, parental compliance with treatment and rehabilitation outcomes for children with ASD (P < 0.05). Through structural equation model analysis, the standardized direct effect of children with ASD from parents' doctor-patient communication efficacy was 0.151 (P= 0.023). The mediating effect of doctor-patient relationship and parental compliance with treatment were 0.160 (P= 0.001) and 0.111 (P= 0.001), respectively, with a chained mediating effect of 0.035 (P= 0.001). The pathway "parental efficacy in doctor-patient communication → doctor-patient relationship → ASD child's rehabilitation outcome" accounted for the highest proportion of the total mediating effect, at 52.29%.

Conclusion Parental doctor-patient communication efficacy may positively impact on the rehabilitation outcomes of children with ASD directly, and indirectly through the doctor-patient relationship and parental compliance with treatment. Rehabilitation institutions should focus on fostering parental communication skills and enhancing high-quality and humanized rehabilitation services.

Key words: autism spectrum disorder, children, doctor-patient communication efficacy, rehabilitation outcome, structural equation model

CLC Number:

R749.93

WEI Ning, ZENG Yanling, JIANG Na, ZHANG Qian, YI Xiaozhe, WANG Jianyun, WANG Dengting, ZHANG Yan, PEI Hongbo, HUANG Chaorong. Impact of parental efficacy in doctor-patient communication on rehabilitation outcomes for children with autism spectrum disorder[J]. Chinese Journal of Rehabilitation Theory and Practice, 2024, 30(5): 577-585.

Figures/Tables 8

Table1

Table 2

The distribution of the scores of each dimension in different feature (n = 519)"

变量	分组	n(%)	PCE	DPR	PTC	REC
性别	男	122 (23.51)	29.42±0.41	12.66±0.17	15.34±0.29	10.49±0.34
性别	女	397 (76.49)	28.88±0.21	12.33±0.09	15.08±0.15	9.68±0.18^a
年龄/岁	18~45	439 (84.59)	28.93±4.34	12.40±1.91	15.13±3.14	9.95±3.52
	46~69	76 (14.64)	29.36±3.60	12.43±1.72	15.18±3.04	9.50±3.80
	≥ 70	4 (0.77)	30.75±2.99	12.86±1.30	14.75±0.50	8.50±4.66
户籍类型	农村	251 (48.36)	28.68±0.26	12.27±0.11	14.86±0.20	9.33±0.22
户籍类型	城镇	268 (51.64)	29.31±0.26	12.54±0.12	15.39±0.19	10.37±0.22^b
婚姻状况	非在婚	71 (13.68)	28.41±0.53	12.23±0.23	14.44±0.34	9.04±0.42
婚姻状况	已婚	448 (86.32)	29.10±0.20	12.43±0.09	15.25±0.15^c	10.00±0.17^d
家庭角色	父亲	94 (18.11)	29.61±4.68	12.60±1.98	15.53±3.32	10.68±3.63
	母亲	357 (68.79)	28.92±4.14	12.36±1.88	15.08±3.14	9.73±3.48
	祖父母	46 (8.86)	28.83±3.62	12.56±1.56	15.20±2.84	9.23±3.97
	外祖父母	15 (2.89)	29.80±3.90	12.55±1.82	14.73±2.19	9.65±4.16
	其他	7 (1.35)	24.57±5.13^e	11.08±2.16	13.43±1.51	10.65±2.47
学历状况	初中及以下	143 (27.55)	28.61±4.00	12.15±1.86	14.87±3.26	9.32±3.69
	高中/中专	137 (26.40)	28.87±4.17	12.58±1.79	15.09±3.14	10.08±3.59
	大专/本科	216 (41.62)	29.36±4.48	12.45±1.94	15.33±2.99	10.04±3.41
	硕士及以上	23 (4.43)	28.91±3.48	12.62±1.90	15.22±3.28	10.45±4.09
当前或曾经从事的职业	无业或待业	217 (41.81)	28.71±4.18	12.33±1.83	15.00±3.30	9.51±3.87
	制造或加工业、建筑或采矿业、运输业等	47 (9.06)	28.15±4.36	12.15±1.80	14.72±2.74	9.74±2.99
	农/林/渔/牧等农业	236 (5.01)	29.54±3.97	11.84±1.65	14.92±2.71	9.40±3.17
	商业/服务业/自由职业	74 (14.26)	29.76±3.94	12.76±1.87	15.54±2.96	9.83±3.56
	行政干部	47 (9.06)	29.13±4.54	12.24±2.00	15.11±3.45	10.16±3.60
	文化教育行业	45 (8.67)	28.96±4.46	12.60±1.81	15.67±2.86	11.43±3.18
	卫生健康行业	27 (5.20)	30.52±4.12	12.78±1.77	15.26±2.90	10.13±2.93
	军人或警察	36 (6.94)	28.69±4.35	12.63±2.32	15.08±3.06	10.10±3.28
家庭类型	核心家庭	238 (45.86)	29.13±4.37	12.52±1.89	15.34±3.26	10.22±3.53
	主干家庭	222 (42.77)	29.02±4.05	12.38±1.87	15.06±2.96	9.88±3.47
	联合家庭	16 (3.08)	29.00±4.23	12.53±1.83	15.06±3.21	10.49±3.96
	单亲/重组家庭	15 (2.89)	28.00±4.94	11.48±1.96	14.53±2.95	8.67±3.57
	留守儿童家庭	19 (3.66)	29.00±4.24	12.27±1.68	15.11±2.66	7.10±3.34
	其他	9 (1.73)	26.89±3.95	11.74±1.80	12.78±3.23	6.89±3.45^f
家庭人均月收入/元	< 1000	86 (16.57)	29.05±3.75	12.22±1.78	15.07±3.17	8.73±3.51
	1000~1999	76 (14.60)	28.67±4.34	12.45±1.75	14.47±3.53	9.81±4.00
	2000~2999	119 (20.93)	29.23±4.37	12.71±1.80	15.72±3.32	10.35±3.53
	3000~3999	105 (20.23)	28.61±4.17	12.23±1.95	14.82±2.44	9.16±3.35
	4000~4999	62 (11.95)	28.79±4.87	12.33±1.99	15.06±2.89	10.65±2.86
	5000~5999	47 (9.06)	29.89±4.23	12.35±2.16	15.28±2.83	10.53±3.45
	≥ 6000	24 (4.62)	29.33±3.37	12.63±1.79	15.88±3.80	11.55±3.92^g

Table 2

Table 3

Figure 1

Table 4

Table 5

Table 6

Table 7

References 30

[1]	HODGES H, FEALKO C, SOARES N. Autism spectrum disorder: definition, epidemiology, causes, and clinical evaluation[J]. Transl Pediatr, 2020, 9: 55-65. doi: 10.21037/tp.2019.09.09 pmid: 32206584
[2]	LORD C, CHARMAN T, HAVDAHL A, et al. The Lancet Commission on the future of care and clinical research in autism[J]. Lancet, 2022, 399(10321): 271-334.
[3]	邹卓, 刘芸, 黄浩宇, 等. 儿童孤独症谱系障碍流行现状和家庭干预的研究及策略[J]. 中国全科医学, 2020, 23(8): 900-907. doi: 10.12114/j.issn.1007-9572.2019.00.717
	ZOU Z, LIU Y, HUANG H Y, et al. Research progress and strategies on family intervention of children with autism spectrum disorder[J]. Chin Gen Prac, 2020, 23(8): 900-907.
[4]	TAN Y Y, HUANG F Y, WANG Y, et al. Effects of exercise intervention based on self-efficacy theory on pregnant women with gestational diabetes mellitus[J]. Z Geburtsh Neonat, 2023, 227(3): 186-196.
[5]	CAPONE V, PETRILLO G. Patient's Communication Perceived Self-efficacy Scale (PCSS): construction and validation of a new measure in a socio-cognitive perspective[J]. Patient Educ Couns, 2014, 95(3): 340-347. doi: 10.1016/j.pec.2014.03.006 pmid: 24690475
[6]	普彦维. YD公司内部沟通效能优化策略研究[D]. 昆明: 云南大学, 2023.
	PU Y W. Research on the optimization strategies for internal communication effectiveness of YD company[D]. Kunming: Yunnan University, 2023.
[7]	喻恂. 精准扶贫中基层政府面向农民的沟通效能研究[D]. 武汉: 华中科技大学, 2021.
	YU X. Research on the communication effectiveness between grassroots government and farmer in accurate poverty alleviation[D]. Wuhan: Huazhong University of Science and Technology, 2021.
[8]	冯玉波, 冷明祥. 试论符号互动论视角下的医患关系[J]. 南京医科大学学报(社会科学版), 2014, 14(2): 125-129.
	FENG Y B, LENG M X. A study of doctor-patient relationship on the perspective of symbolic interactionism[J]. J Nanjing Med Univ (Soc Sci), 2014, 14(2): 125-129.
[9]	CHANG D S, CHEN W L, WANG R W. Impact of the bidirectional relationship between communication and cognitive efficacy on orthopedic patient adherence behavior[J]. BMC Health Serv Res, 2022, 22(1): 199.
[10]	马菁宜, 邹姮. 基于帕森斯"病人角色"理论的儿科病人角色与医患关系分析[J]. 中国医学伦理学, 2023, 36(7): 709-713.
	MA J Y, ZOU H. Analysis on pediatric sick role and doctor-patient relationship based on Parsons' Theory of "Sick Role"[J]. Chin Med Ethics, 2023, 36(7): 709-713.
[11]	陈倩雯, 郑红娥. 国内外医患关系研究述评[J]. 医学与哲学(A), 2014, 35(3): 44-48.
	CHEN Q W, ZHENG H E. Review of research on doctor-patient relationship at home and abroad[J]. Med Philosophy (A), 2014, 35(3): 44-48.
[12]	宋雪静, 牛润桂. 浅谈医患沟通在医患关系中的重要性[J]. 医学食疗与健康, 2020, 18(24): 190-191.
	SONG X J, NIU R G. Discussion on the importance of doctor-patient communication in doctor-patient relationship[J]. Med Diet Health, 2020, 18(24): 190-191.
[13]	ZOLNIEREK K B, DIMATTEO M R. Physician communication and patient adherence to treatment: a meta-analysis[J]. Med Care, 2009, 47(8): 826-834. doi: 10.1097/MLR.0b013e31819a5acc pmid: 19584762
[14]	DU L, WU R H, CHEN X, et al. Role of treatment adherence, doctor-patient trust, and communication in predicting treatment effects among tuberculosis patients: difference between urban and rural areas[J]. Patient Prefer Adher, 2020, 14: 2327-2336. doi: 10.2147/PPA.S277650 pmid: 33262582
[15]	XU B. The impact of COVID-19 on the doctor-patient relationship in China[J]. Front Public Health, 2022, 10: 907009.
[16]	胡蝶, 郑亚楠, 尹梅, 等. 精神医学医患关系模式探讨:基于萨斯-荷伦德模式[J]. 中国医学伦理学, 2023, 36(9): 1007-1011.
	HU D, ZHENG Y N, YIN M, et al. Discussion on the doctor-patient relationship model in psychiatry based on the Szasz & Hollender's Model of doctor-patient relationship[J]. Chin Med Ethics, 2023, 36(9): 1007-1011.
[17]	袁静, 赵琼姝, 刘锦钰, 等. 儿科医患沟通及其影响因素探讨[J]. 中国医学伦理学, 2021, 34(2): 162-167.
	YUAN J, ZHAO Q S, LIU J Y, et al. Discussion on communication and its influencing factors between doctors and patients in pediatrics[J]. Chin Med Ethics, 2021, 34(02): 162-167.
[18]	牛春艳. 某康复机构孤独症儿童康复效果影响因素分析[D]. 长春: 吉林大学, 2017.
	NIU C Y. Analysis on influencing factors of rehabilitation effect of children with autism in a rehabilitation institution[D]. Changchun: Jilin University, 2017.
[19]	王先伟, 蒲亨萍, 杨光会, 等. 孤独症患儿家长赋能现状及其影响因素分析[J]. 中华护理杂志, 2022, 57(10): 1219-1224. doi: 10.3761/j.issn.0254-1769.2022.10.010
	WANG X W, PU H P, YANG G H, et al. Analysis of the current situation of family empowerment of children with autism and its influencing factors[J]. Chin J Nurs, 2022, 57(10): 1219-1224. doi: 10.3761/j.issn.0254-1769.2022.10.010
[20]	麦依萍, 杜亚松. 孤独谱系障碍患儿的家庭干预研究进展[J]. 中国儿童保健杂志, 2023, 31(12): 1335-1339. doi: 10.11852/zgetbjzz2023-0112
	MAI Y P, DU Y S. Research advance in family intervention for children with autism[J]. Chin J Child Health Care, 2023, 31(12): 1335-1339.
[21]	LORD C, BRUGHA T S, CHARMAN T, et al. Autism spectrum disorder[J]. Nat Rev Dis Primers, 2020, 6(1): 5. doi: 10.1038/s41572-019-0138-4 pmid: 31949163
[22]	谢桂芳, 易泉英, 曾娟, 等. 儿童孤独症家庭干预治疗依从性实施效果影响因素调查与分析[J]. 护理实践与研究, 2019, 16(11): 8-10.
	XIE G F, YI Q Y, ZENG J, et al. Investigation and analysis of factors influencing the implementation effect of family intervention compliance in children with autism[J]. Nurs Pract Res, 2019, 16(11): 8-10.
[23]	张雅如, 陶洪梅, 阳光, 等. 专业人员指导下孤独症谱系障碍儿童家长执行的家庭康复疗效观察的前瞻性研究[J]. 中国当代儿科杂志, 2021, 23(12): 1256-1261.
	ZHANG Y R, TAO H M, YANG G, et al. Efficacy of family rehabilitation treatment performed by parents under the guidance of professionals in children with autism spectrum disorder: a prospective study[J]. Chin J Contemp Pediatr, 2021, 23(12): 1256-1261.
[24]	盛威威, 李欣, 邱卓英, 等. 残疾儿童康复需求与康复服务发展研究[J]. 中国康复理论与实践, 2020, 26(5): 502-507. doi: 10.3969/j.issn.1006-9771.2020.05.002
	SHENG W W, LI X, QIU Z Y, et al. Unmet needs and service of rehabilitation for children with disabilities[J]. Chin J Rehabil Theory Pract, 2020, 26(5): 502-507.
[25]	李晓捷, 庞伟, 郭津. 中国儿童康复事业1980-2020年发展历程回顾与展望[J]. 中国康复理论与实践, 2020, 26(8): 869-880. doi: 10.3969/j.issn.1006-9771.2020.08.001
	LI X J, PANG W, GUO J. Review and prospects of development of rehabilitation for children in China from 1980 to 2020[J]. Chin J Rehabil Theory Pract, 2020, 26(8): 869-880.
[26]	梁靖. 中国式现代化视域下健康人文教育现代化的内涵与进路[J]. 西北大学学报(哲学社会科学版), 2024, 54(1): 169-180.
	LIANG J. The connotations and approaches of modernization of healthy humanities education from Chinese-style modernization[J]. J Northwest Univ (Philos Soc Sci Ed), 2024, 54(1): 169-180.
[27]	WANG Z Y, ZHANG X, HAN D M, et al. How the use of an online healthcare community affects the doctor-patient relationship: an empirical study in China[J]. Front Public Health, 2023, 11: 1145749.
[28]	杨泽荣. 长治市孤独症儿童康复服务供需双方现状研究[D]. 北京: 北京协和医学院, 2022.
	YANG Z R. Research on the current situation of supply and demand sides of rehabilitation services for children with autism in Changzhi city[D]. Beijing: Peking Union Medical College, 2022.
[29]	郭凤. 长沙孤独症康复机构能力建设问题与对策研究[D]. 长沙: 湖南大学, 2022.
	GUO F. The research on the problems and countermeasures in capacity building of Changsha autism rehabilitation institutions[D]. Changsha: Hunan University, 2022.
[30]	熊淑萍, 李文炜, 王坚. 自闭症儿童康复路径国内外研究现状[J]. 中国健康心理学杂志, 2022, 30(12): 1902-1908.
	XIONG S P, LI W W, WANG J. Review of domestic and foreign research on rehabilitation pathway of autistic children[J]. Chin J Health Psychol, 2022, 30(12): 1902-1908.

潜变量	潜变量命名	测量变量	测量变量命名
家长医患沟通效能	PCE	沟通使我对孩子的病情有了清晰认知	PCE1
		沟通使我得到服务过程中的指导帮助	PCE2
		沟通使我增强了对孩子的康复信心	PCE3
		沟通使我得到了康复人员的关心友善	PCE4
		沟通使孩子的康复效果得到实质改善	PCE5
医患关系	DPR	康复人员服务态度的认可	DPR1
		康复人员服务能力的认可	DPR2
		家长康复服务体验感受	DPR3
家长治疗依从性	PTC	遵循康复训练方案及内容	PTC1
		遵循康复训练方法及技巧	PTC2
		遵循康复训练要求时长	PTC3
家庭社会特征	FSC	主要照顾者身份	FSC1
		家庭人均月收入	FSC2
		家庭类型	FSC3
		家庭户籍类别	FSC4
ASD儿童康复效果	REC	社会和(或)交流能力	REC1
		狭窄、重复和刻板的行为模式、兴趣和活动	REC2
		其他症状	REC3

变量	家长医患沟通效能	医患关系	家长治疗依从性	ASD儿童康复效果
家长医患沟通效能	1.000
医患关系	0.611^a	1.000
家长治疗依从性	0.448^a	0.420^a	1.000
ASD儿童康复效果	0.380^a	0.374^a	0.360^a	1.000

拟合指标	χ²/df	RMSEA	GFI	AGFI	NFI	RFI	IFI	TLI	CFI
检验值	2.587	0.055	0.933	0.913	0.946	0.938	0.966	0.961	0.966
检验结果	理想	理想	理想	理想	理想	理想	理想	理想	理想
参考值	< 3	< 0.08	> 0.9	> 0.9	> 0.9	> 0.9	> 0.9	> 0.9	> 0.9

假设	路径关系	非标准化路径系数	标准化路径系数	标准误	临界比	P值	假设结果
H1	PCE→DPR	0.511	0.639	0.032	15.945	< 0.001	支持
H2	PCE→PTC	0.430	0.406	0.067	6.392	< 0.001	支持
H3	PCE→REC	0.206	0.151	0.090	2.280	0.023	支持
H4	DPR→PTC	0.268	0.202	0.076	3.541	< 0.001	支持
H5	PTC→REC	0.259	0.201	0.078	3.308	< 0.001	支持
H6	DPR→REC	0.313	0.184	0.102	3.065	0.002	支持
H7	FSC→PCE	0.974	0.307	0.017	55.809	< 0.001	支持
H8	FSC→REC	1.061	0.245	0.037	28.853	< 0.001	支持

维度	直接效应	间接效应	总效应
FSC	0.245	0.115	0.360
PCE	0.151	0.225	0.376
DPR	0.184	0.041	0.225
PTC	0.201	-	0.215

Impact of parental efficacy in doctor-patient communication on rehabilitation outcomes for children with autism spectrum disorder

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路径	效应	效应值	95%CI	P值	效应占比/%
PCE→DPR→REC	间接效应	0.160	0.064~0.271	0.001	52.29
PCE→PTC→REC	间接效应	0.111	0.048~0.197	0.001	36.27
PCE→DPR→PTC→REC	间接效应	0.035	0.013~0.074	0.001	11.44
PCE→REC	总间接效应	0.306	0.190~0.447	< 0.001	100.00

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