本文選題：多重干預(yù)　切入點(diǎn)：社區(qū)　出處：《上海交通大學(xué)》2015年碩士論文

【摘要】：研究目的:隨著經(jīng)濟(jì)水平和生活質(zhì)量的不斷提高,生活方式的改變和老齡化情況的不斷加重,使得越來越多的人罹患2型糖尿病。目前,中國面臨糖尿病患病數(shù)量巨大,控制問題異常嚴(yán)峻的現(xiàn)狀。盡管,近年來各地政府著重強(qiáng)調(diào)社區(qū)診療,家庭醫(yī)生規(guī)范管理的積極作用,但仍然無法滿足日益增長的患病群體的控制問題。2型糖尿病的發(fā)生發(fā)展不僅受到遺傳和環(huán)境的雙重作用,由于疾病本身的長期性,患者往往存在各種心理問題,其中以抑郁最為多見。同時,由于身心問題的交織,對患者的生活亦產(chǎn)生了很多負(fù)面影響,睡眠問題在糖尿病合并抑郁的患者中呈現(xiàn)高發(fā)比例。由糖尿病引起的病理生理變化、各種心理問題,以及不良的生活方式等,使糖尿病良好控制面臨很大挑戰(zhàn)。面對復(fù)雜的患有身心疾病的個體,除了要不斷探索有效的糖尿病診治技術(shù)外,加強(qiáng)患者的健康教育和行為支持至關(guān)重要,促進(jìn)健康生活方式的建立至關(guān)重要。近年,專業(yè)領(lǐng)域在同伴支持、移動醫(yī)療技術(shù)和舒緩音樂對慢性疾病自我管理支持方面的研究正在興起。同伴支持作為患者互助和社會支持的一種形式,有助于優(yōu)化糖尿病的管理,持續(xù)為糖尿病患者提供社會和情感支持,協(xié)助病患更好地改進(jìn)日常生活中的健康行為;移動醫(yī)療通過移動信息技術(shù)支持臨床治療和健康管理,通過智能應(yīng)用程序,可以幫助醫(yī)師更好地了解患者日常控制情況及困擾及時給予指導(dǎo),使糖尿病管理更加個體化,提高疾病的管理效率;舒緩音樂療法作為一種特定的治療手段,被應(yīng)用在很多心理疾病上,在一些合并身心疾患的慢性病個體,針對某些癥狀,如睡眠障礙,舒緩音樂通過激活大腦邊緣系統(tǒng)可改善生理心理狀態(tài),進(jìn)而可收到良好的改善癥狀的效果。本研究針對社區(qū)2型糖尿病,比較常規(guī)社區(qū)臨床治療聯(lián)合同伴支持、移動醫(yī)療技術(shù)和舒緩音樂等多重干預(yù)對患病個體在臨床指標(biāo)、健康行為以及特定合并狀態(tài),如抑郁、睡眠障礙等的綜合管理效果,評價多重干預(yù)在社區(qū)糖尿病管理中付諸實(shí)踐之必要性和可行性。研究方法:(1)第一階段(0-6月):在上海市黃浦區(qū)瑞金二路街道社區(qū)衛(wèi)生服務(wù)中心建檔的1492名2型糖尿病患者中,根據(jù)項目入選/排除標(biāo)準(zhǔn),招募193名自愿參加項目的研究對象。按照隨機(jī)化原則,將所有入組患者分成同伴支持組(96名)和常規(guī)社區(qū)治療組(97名)。同伴支持組分成6個小組,每個小組配備2名經(jīng)考核合格的同伴支持小組組長,開展為期6個月的觀察。評價兩組患者h(yuǎn)ba1c、糖尿病相關(guān)知識、糖尿病自我管理行為和自我效能的前后差異。(2)第二階段(7-13月):在以上患者中,經(jīng)過一個月的洗脫期(第7個月),再行篩選存在抑郁狀態(tài)和睡眠障礙患者45名,將其分成多重干預(yù)組(22名)和常規(guī)社區(qū)治療組(23名)。多重干預(yù)組分成3個小組,每小組由2名同伴組長組織日常活動,多重干預(yù)組的患者均使用手機(jī),并安裝糖尿病健康管理平臺。第8-10個月,社區(qū)醫(yī)生、同伴組長和同伴小組成員利用智能健康管理平臺,加強(qiáng)糖尿病治療和自我管理支持,重點(diǎn)就心理舒緩、睡眠健康管理等給予指導(dǎo)。第11-13個月,多重干預(yù)組在同伴支持、移動醫(yī)療技術(shù)基礎(chǔ)上再指導(dǎo)給予睡前舒緩音樂治療。第8-13個月,常規(guī)社區(qū)治療組患者接受常規(guī)社區(qū)疾病治療和健康教育。分別在第8、10、13個月時進(jìn)行評估,比較兩組患者血糖控制(hba1c)、睡眠質(zhì)量(psqi量表)、抑郁癥狀(phq-9抑郁量表)、糖尿病知識、糖尿病自我管理行為和自我效能變化。研究結(jié)果:(1)臨床治療單純聯(lián)合同伴支持組的患者較常規(guī)社區(qū)治療組,其hba1c在6個月時改善效果更好,且統(tǒng)計學(xué)差異(7.15±1.04vs7.53±1.63,p0.05);其自我效能亦有所提升,兩組得分有統(tǒng)計學(xué)差異(109.20±13.88vs102.09±14.67,p0.05)。(2)臨床治療聯(lián)合同伴支持和移動醫(yī)療技術(shù)后,用phq-9評價患者抑郁干預(yù)效果,多重干預(yù)組較常規(guī)社區(qū)治療組在改善抑郁方面效果更為顯著,且與第二階段初始時比較,自身前后有明顯改善(4.43±4.09vs8.09±2.45,p0.05);用psqi評價患者睡眠質(zhì)量干預(yù)效果,多重干預(yù)組較常規(guī)社區(qū)治療組在改善患者睡眠質(zhì)量效果上更為顯著;自身前后亦有改善(9.62±4.04vs12.36±4.00,p0.05);在多重干預(yù)的基礎(chǔ)上再聯(lián)合舒緩音樂后,睡眠量表評價顯示多重干預(yù)對改善抑郁的效果又有進(jìn)一步的提升(2.55±1.67vs5.95±4.02,p0.05);且多重干預(yù)組自身睡眠質(zhì)量也有改善(8.81±4.43vs12.36±4.00,p0.05)。研究結(jié)論:(1)在常規(guī)臨床治療基礎(chǔ)上,聯(lián)合多重干預(yù),如同伴支持、移動醫(yī)療技術(shù)和舒緩音樂,對幫助社區(qū)2型糖尿病患者進(jìn)一步改善臨床治療效果、自我管理行為以及疾病相關(guān)伴隨狀態(tài)等具有良好效果;(2)在社區(qū)開展糖尿病綜合防止中,應(yīng)該全力推動多重干預(yù)手段的實(shí)踐和應(yīng)用,以進(jìn)一步提升糖尿病防控效果,同時也將為其他慢性病的防控和管理積累經(jīng)驗,豐富干預(yù)手段,不斷提升臨床效果,以及推動改善衛(wèi)生經(jīng)濟(jì)學(xué)成效發(fā)揮良好作用。
[Abstract]:Purpose: with the quality level of the economy and improvement of life, change the way of life and the aging situation continues to increase, making more and more people suffering from type 2 diabetes. At present, the prevalence of diabetes China facing huge amount, control problem serious. Although in recent years, local governments emphasize community clinics, actively the role of family doctors standardized management, but still can not meet the occurrence and development of type.2 diabetes control group of growing not only influenced by both genetic and environmental, due to the long-term nature of the disease itself, often with various psychological problems, including depression is the most common. At the same time, by interleaving the physical and mental problems. Also produced a lot of negative impact on the lives of patients, showing a high incidence of sleep problems in the proportion of diabetes with depression patients. Pathology caused by diabetes students Physical changes, a variety of psychological problems, and the bad way of life, to make good control of diabetes facing great challenges. In the face of the complex with the individual physical and mental diseases, in addition to continuously explore effective techniques for diagnosis and treatment of diabetes patients, strengthen the health education and behavior support is crucial, it is important to establish and promote a healthy lifestyle. In recent years, the field of professional in peer support, mobile medical technology and soothing music on chronic disease self-management support research is on the rise. Peer support as a form of mutual aid patients and social support, help to optimize the management of diabetes, continue to provide social and emotional support to patients with diabetes, to help patients better improvement in daily life health behavior; mobile medical support clinical treatment and health management through mobile information technology, through the intelligent application, can help physicians To better understand the daily control and distress in patients with timely guidance, make diabetes management more individualized, improve disease management efficiency; soothing music therapy as a specific treatment method, is used in many mental illnesses, in some individuals with physical and mental disorders of chronic disease, the symptoms, such as sleep disorders, soothing the music through the activation of the limbic system can improve the physiological and psychological state, and received good effect can improve symptoms. In this study, the community type 2 diabetes, compared with conventional clinical treatment combined with community peer support, mobile medical technology and soothing music intervention on multiple affected individuals in clinical indicators, health behavior and the specific combined state, such as depression and sleep disorders such as the comprehensive management effect, the necessity of the evaluation of multiple intervention into practice in community management of diabetes in the study and feasibility. Methods: (1) the first stage (0-6 months) in 1492 patients with type 2 diabetes mellitus in Shanghai city of Huangpu District road two Ruijin street community health service centers, according to the inclusion / exclusion criteria, the recruitment of 193 volunteer subjects. According to the principle of randomization, all 20 patients were divided into peer support group (96) and conventional treatment group (97 cases) community. Peer support group was divided into 6 groups, each group with 2 certified peer support team leader, to carry out the observation period of 6 months. The two groups were evaluated by HbA1c, diabetes related knowledge, self-management of diabetes and self-efficacy before and after difference. (2) the second phase (7-13 months): in these patients, one month after the washout period (seventh months), and for screening patients with depression and sleep disorder in 45, divided into multiple intervention group (22 cases) and conventional treatment group (23 patients in community ). Multi intervention group was divided into 3 groups, each group consisted of 2 peer leader is to organize daily activities, multiple intervention group of patients using the mobile phone, and install the health management platform for diabetes. The 8-10 months of community doctors, peer peer leader and team members using intelligent health management platform, strengthen the treatment of diabetes mellitus and self management support and focus on psychology, sleep health management guidance. In 11-13 months, the intervention group in multiple peer support, based on the mobile medical technology to guide to bedtime soothing music therapy - 8-13 months, conventional community treatment received routine community disease treatment and health education were assessed in the first 8,10,13. Months respectively, compared two groups of patients with blood glucose control (HbA1c), sleep quality (PSQI scale), depressive symptoms (PHQ-9 Depression Scale), diabetes knowledge, self-management behavior changes in diabetes and self-efficacy. Results: (1) the clinical treatment of simple combined with peer support group of patients than the conventional community treatment group, the HbA1c has better effect in 6 months, and the statistical difference (7.15 + 1.04vs7.53 + 1.63, P0.05); the self efficiency is also improved, there is significant difference between the two groups score (109.20 + 13.88vs102.09 + 14.67, P0.05). (2) clinical treatment combined with peer support and mobile medical technology, with the effect of depression in patients with intervention of PHQ-9 evaluation, multiple intervention group compared with the conventional community treatment group in improving depression effect is more significant, and compared with second initial stage, significantly improved before and after (4.43 + 4.09vs8.09 + 2.45, P0.05 the effect of the sleep quality of the patients); PSQI intervention evaluation, multiple intervention group compared with the conventional community in improving the patients' sleep quality effect is more obvious; there are also self improvement (9.62 + 4.04vs12.36 + 4, P0.05); in the multi intervention 鐨勫熀紜，

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