【摘要】：目的:通過定量研究和定性研究相結(jié)合的方法,從基層醫(yī)療機(jī)構(gòu)供方和慢性病患者需方的角度,了解遵義市慢性病健康管理服務(wù)開展的現(xiàn)狀和需求,為該地區(qū)完善慢性病健康管理服務(wù)提供循證決策依據(jù)。方法:采用分層隨機(jī)抽樣方法,隨機(jī)抽取具有代表性的遵義市紅花崗區(qū)8個(gè)基層醫(yī)療機(jī)構(gòu)作為研究地點(diǎn)。通過問卷調(diào)查了解慢性病人的一般情況、行為生活方式、健康狀況以及對(duì)慢性病健康管理知曉、利用、評(píng)價(jià)情況。通過目的抽樣方法,對(duì)遵義市疾控中心分管慢性病健康管理的領(lǐng)導(dǎo)及所屬8個(gè)基層醫(yī)療機(jī)構(gòu)分管公共衛(wèi)生的院長(zhǎng)或主任和慢性病健康管理衛(wèi)生服務(wù)人員進(jìn)行個(gè)人深入訪談,了解慢性病健康管理的服務(wù)模式、服務(wù)效果、軟硬件條件、存在的問題及影響因素等。調(diào)查數(shù)據(jù)采用Epidata3.1軟件建立數(shù)據(jù)庫(kù),使用spss17.0統(tǒng)計(jì)軟件進(jìn)行分析,并運(yùn)用卡方檢驗(yàn)和二分類logistic回歸分析探索影響慢性病發(fā)病的相關(guān)因素。所有定性資料采用國(guó)際上普遍使用的框架分析方法(Thematic Framework)對(duì)資料進(jìn)行整理和分析。結(jié)果:1.遵義市基層醫(yī)療機(jī)構(gòu)慢性病健康管理開展的現(xiàn)狀調(diào)查發(fā)現(xiàn),(1)在衛(wèi)生服務(wù)提供方方面,基層醫(yī)療機(jī)構(gòu)衛(wèi)生服務(wù)人員大多數(shù)為女性,專業(yè)多為護(hù)理專業(yè),職稱多為初級(jí)職稱;大多數(shù)(7/8)被調(diào)查的基層醫(yī)療機(jī)構(gòu)都按照《2015年版國(guó)家基本公共衛(wèi)生規(guī)范》實(shí)施了慢性病健康管理服務(wù)的模式和流程;個(gè)人深入訪談?wù){(diào)查顯示,慢性病健康管理隨訪評(píng)估和體檢的利用是最好的,大多數(shù)(5/8)的社區(qū)認(rèn)為分類干預(yù)的利用最差。慢性病患者對(duì)慢性病健康管理項(xiàng)目的滿意度都比較高。基層醫(yī)療機(jī)構(gòu)改進(jìn)慢性病健康管理的策略主要有:在小區(qū)貼宣傳單,增加檢查項(xiàng)目,給居民免費(fèi)發(fā)放藥品。慢性病健康管理存在的問題:慢性病健康管理本身的原因;人力資源匱乏;設(shè)備不足,藥品單一缺乏;國(guó)家財(cái)政經(jīng)費(fèi)投入力度不夠;多部門合作不協(xié)調(diào);考核方面的問題。(2)對(duì)慢性病患者問卷調(diào)查結(jié)果表明,居民對(duì)基本公共衛(wèi)生服務(wù)的知曉、利用、滿意情況總體比較好,高血壓的隨訪評(píng)估和分類干預(yù)的知曉、利用、滿意度情況偏低,年齡、居住地、職業(yè)是高血壓篩查知曉的相關(guān)因素,城市戶口居民的高血壓篩查知曉率高于農(nóng)村戶口的居民(P0.05),年齡是高血壓健康體檢知曉的相關(guān)因素,50-60歲的居民對(duì)高血壓健康體檢的知曉高于50歲的居民(P0.05)。年齡是高血壓健康體檢利用的相關(guān)因素,50-60歲的居民對(duì)高血壓健康體檢的利用高于50歲的居民(P0.05),年齡、調(diào)查社區(qū)、居住地、職業(yè)是糖尿病篩查知曉的相關(guān)因素,50歲的居民對(duì)糖尿病篩查的知曉高于50-60、60-70歲的居民(P0.05),城市居民對(duì)糖尿病篩查的知曉高于農(nóng)村居民(P0.05),年齡、居住地、婚姻狀況是糖尿病篩查利用的相關(guān)因素,50-60歲的居民糖尿病篩查的利用高于50、60-70歲的居民(P0.05)。2.遵義市基層醫(yī)療機(jī)構(gòu)慢性病健康管理開展的需求評(píng)估調(diào)查表明,(1)慢性病患病負(fù)擔(dān)重,該人群患有10種NCDs,其中57.6%的被調(diào)查者患有兩種以上的NCDs,患病率從高到低依次為高血壓(54.6%),糖尿病(20.1%),血脂異常(13.4%),冠心病(11.7%),慢性支氣管炎(8.4%),骨質(zhì)疏松(5.7%),腦卒中(3.5%),肥胖(2.7%),肺氣腫(1.5%),慢阻肺(0.7%);調(diào)查發(fā)現(xiàn)行為生活方式有待改進(jìn),被調(diào)查者中,36.1%的人缺乏運(yùn)動(dòng),吸煙率為16.1%,飲酒率為7.9%,18.3%的人睡眠時(shí)間小于5小時(shí),40.5%的人食用蔬菜不足300克,12%的人經(jīng)常食用甜食,16.1%的人口味偏咸。(2)通過個(gè)人深入訪談?wù){(diào)查發(fā)現(xiàn),除了高血壓和糖尿病,還有以下的疾病需要管理起來:冠心病、腦梗塞、心肌梗塞、高血脂,雖然慢性病健康管理衛(wèi)生服務(wù)人員對(duì)患者進(jìn)行了行為生活方式的指導(dǎo),但仍然存在不良生活方式和飲食習(xí)慣,需要優(yōu)先解決的健康問題是:體檢項(xiàng)目需要增加,隨訪評(píng)估和分類干預(yù)項(xiàng)目應(yīng)規(guī)范執(zhí)行,衛(wèi)生服務(wù)人員的專業(yè)能力需要提高。在可利用于慢性病健康管理的衛(wèi)生資源方面,衛(wèi)生服務(wù)人員希望基層醫(yī)療機(jī)構(gòu)能夠和醫(yī)保、社保聯(lián)合起來,雙向轉(zhuǎn)診制度要切實(shí)實(shí)施起來,希望政府媒體、街道、居委會(huì)參與宣傳活動(dòng)。結(jié)論:1.基層醫(yī)療機(jī)構(gòu)實(shí)施慢性病健康管理衛(wèi)生服務(wù)的能力不足,有基層醫(yī)療機(jī)構(gòu)沒有完全按照基本公共衛(wèi)生服務(wù)規(guī)范實(shí)施。2.國(guó)家對(duì)社區(qū)慢性病健康管理宣傳不到位,居民對(duì)社區(qū)慢性病健康管理認(rèn)識(shí)不足。3.調(diào)查地區(qū)居民的慢性病負(fù)擔(dān)較重,該地區(qū)基本公共衛(wèi)生項(xiàng)目中慢性病管理的疾病應(yīng)該除糖尿病和高血壓外,應(yīng)逐漸擴(kuò)充,將血脂異常、冠心病等納入健康管理。4.生活方式中應(yīng)加強(qiáng)對(duì)運(yùn)動(dòng)、睡眠、吸煙飲酒及蔬菜攝入不足、鹽和糖控制的干預(yù)和指導(dǎo)。5.基層醫(yī)療機(jī)構(gòu)開展慢性病健康管理還面臨著項(xiàng)目本身要求的不合理,居民健康意識(shí)不高,人力物力缺乏,國(guó)家經(jīng)費(fèi)投入不足,多部門合作不協(xié)調(diào)的挑戰(zhàn)。
[Abstract]:Objective: through the combination of quantitative and qualitative research methods, from the point of view of the supply side of the basic medical institutions and the demand side of the patients with chronic diseases, the present situation and demand of the health management service of chronic diseases in Zunyi are understood, and the evidence-based decision basis is provided for the improvement of the health management service of chronic diseases in this area. 8 grass-roots medical institutions in Zunyi red granite district were selected as the research sites. Through questionnaire survey, the general situation, behavior life style, health status, awareness, utilization and evaluation of chronic disease health management were investigated. The chronic disease health of Zunyi CDC was divided by the purpose sampling method. Management leaders and 8 grass-roots medical institutions in charge of public health director or director and chronic health management health service personnel to conduct personal in-depth interviews to understand the service mode of chronic disease health management, service effect, software and hardware conditions, existing problems and influencing factors. The survey data are established by Epidata3.1 software. According to the library, the SPSS17.0 statistical software was used to analyze, and the related factors affecting the chronic disease were explored by chi square test and two classification logistic regression analysis. All qualitative data were analyzed by the international general framework analysis (Thematic Framework) method. Results: 1. the grass-roots medical institutions in Zunyi were slow. The investigation of the status of STD health management found that (1) in the health service provider, most of the health service personnel in the grass-roots medical institutions are women, the major are nursing specialties, and most of the professional titles are primary titles; most of the primary medical institutions investigated in 7/8 have implemented chronic diseases according to the national basic public health norms of the <2015 edition. The model and process of health management service; personal in-depth interview survey showed that the health management follow-up assessment and the use of physical examination were the best. Most of the (5/8) community considered the worst use of classified intervention. The chronic disease patients were satisfied with the chronic disease health management projects. The basic medical institutions improved the chronic disease health. The strategy of management mainly include: putting up the Publicity sheet in the District, increasing the inspection items and giving the residents free medicine. The problems of the chronic disease health management: the cause of the chronic disease health management itself; the lack of human resources; the lack of equipment and the single drug; the state financial expenditure is not enough; the multi department cooperation is incompatible; the assessment aspects are not coordinated. (2) the questionnaire survey of the patients with chronic diseases showed that the residents' awareness, utilization and satisfaction of basic public health services were generally better, the follow-up evaluation of hypertension and the awareness of classified intervention, utilization, low satisfaction, age, residence and occupation were the related factors of the awareness of hypertension screening, and the hypertension of urban household residents The awareness rate of screening was higher than that of rural residents (P0.05). Age was a related factor for health examination of hypertension. The awareness of health examination for hypertension was higher than that of 50 year old residents (P0.05). Age was the related factor of health examination for hypertension, and the health examination of hypertension was higher than 50 years old for the residents of 50-60 years old. People (P0.05), age, investigation community, residence, occupation are the related factors of the awareness of diabetes screening. The awareness of diabetes screening for 50 year old residents is higher than that of 50-60,60-70 year old residents (P0.05). The awareness of diabetes screening in urban residents is higher than that of rural residents (P0.05), age, residence, and marital status are related factors for the use of diabetes screening. The use of diabetes screening for 50-60 year old residents was higher than that of 50,60-70 years old residents (P0.05).2. Zunyi grass-roots medical institutions' chronic disease health management. (1) the burden of chronic disease was heavy, the population had 10 kinds of NCDs, of which 57.6% of the respondents had more than two NCDs, and the prevalence rate was higher from high to low. Blood pressure (54.6%), diabetes (20.1%), dyslipidemia (13.4%), coronary heart disease (11.7%), chronic bronchitis (8.4%), osteoporosis (5.7%), cerebral apoplexy (3.5%), obesity (2.7%), emphysema (1.5%), and slow resistance lung (0.7%); the investigation found that the way of living living needs to be improved, among the respondents, 36.1% people were lack of exercise, smoking rate 16.1%, drinking rate 7.9%, 18.3% People sleep less than 5 hours, 40.5% of the people who eat vegetables less than 300 grams, 12% of the people often eat sweet food, 16.1% people taste salty. (2) through personal in-depth interview survey found that, in addition to hypertension and diabetes, and the following diseases need to be managed: coronary heart disease, cerebral infarction, myocardial infarction, hyperlipidemia, although chronic disease health management guard Health service personnel guide the patient's behavior lifestyle, but there is still a bad lifestyle and eating habits. The health problems that need to be given priority are: medical items need to be increased, follow-up evaluation and classification intervention should be standardized, and the professional ability of health service personnel needs to be improved. With regard to the management of health resources, health service personnel hope that grass-roots medical institutions can be combined with medical insurance and social security, and the two-way referral system should be implemented effectively. It is hoped that the government media, the streets and the neighborhood committees should participate in publicity activities. Conclusion: 1. the basic medical institutions of the grass-roots medical institutions have insufficient ability to implement health services for chronic diseases and health services, and have grass-roots medical machines. The health management of the community chronic diseases is not fully implemented according to the basic public health service standards, and the residents are less aware of the chronic diseases in the community. The chronic disease burden of the residents in the area of the community chronic disease management is less than.3., and the chronic disease management in the basic public health projects in this area should be divided into diabetes and hypertension. It should be expanded gradually, the blood lipid abnormality, coronary heart disease and so on should be incorporated into the health management.4. lifestyle. It is necessary to strengthen the exercise, sleep, smoking and drinking and the insufficient intake of vegetables. The intervention and guidance of salt and sugar control and guidance for the.5. grass-roots medical institutions to carry out the health management of chronic diseases is still facing the unreasonable requirements of the project, the health consciousness of the residents is not high, and the human and materials are not high. Lack of power, insufficient investment from the state, and uncoordinated multi sectoral cooperation.
【學(xué)位授予單位】：遵義醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R197.61

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